Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?
Elevate extremities on pillows.
Evaluate edema for pitting.
Wrap the feet with warmed blankets.
Assess pulses with a vascular Doppler
The Correct Answer is D
A. Elevate extremities on pillows:
While elevation can be beneficial for reducing dependent edema, the priority is to assess the pulses first to determine the adequacy of peripheral perfusion.
B. Evaluate edema for pitting:
Assessing edema for pitting is important for gathering additional information, but it is not the initial action in this scenario. Assessing pulses is more critical to evaluate perfusion.
C. Wrap the feet with warmed blankets:
Warming the feet with blankets may be appropriate in some situations, but it is not the priority when the client is exhibiting edema and non-palpable pedal pulses. The primary concern is assessing perfusion.
D. Assess pulses with a vascular Doppler:
This is the correct action. The non-palpable pedal pulses are concerning and require immediate assessment to determine the status of peripheral perfusion. Using a vascular Doppler will help the nurse assess the presence or absence of blood flow in the lower extremities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hyperactive bowel sounds.
Hyperactive bowel sounds are more suggestive of gastrointestinal issues, such as intestinal hypermotility or increased peristalsis. While diabetes can affect the gastrointestinal system, hyperactive bowel sounds are not a specific indicator of the symptoms described by the client.
B. Anxiety and sighing.
Anxiety and sighing are more indicative of emotional or psychological factors rather than dehydration. While stress can impact blood sugar levels in individuals with diabetes, anxiety and sighing are not direct signs of the dehydration that may be associated with the reported symptoms.
C. Dark yellow urine.
Dark yellow urine can be a sign of concentrated urine, suggesting dehydration. In diabetes, especially when blood sugar levels are elevated, increased urine production (polyuria) can lead to dehydration. Dark yellow urine may indicate that the urine is more concentrated due to a lack of fluid intake.
D. Myalgia in wrists and hands.
Myalgia in the wrists and hands is not a typical symptom of dehydration related to diabetes. It could be associated with various conditions, such as musculoskeletal issues or nerve-related problems. This symptom is less likely to be directly linked to the reported weakness and palpitations.
Correct Answer is A
Explanation
A. Discuss approaches to chronic pain control with the client:
This is the correct answer. Heberden's nodes are bony enlargements that can occur in osteoarthritis, particularly in the joints of the fingers. These nodes can be associated with pain. Discussing approaches to chronic pain control with the client is an appropriate nursing intervention to address the client's pain and improve quality of life.
B. Review the client's dietary intake of high-protein foods:
Dietary intake of high-protein foods is not directly related to the management of Heberden's nodes in degenerative joint disease. Pain control and joint protection measures are more relevant.
C. Notify the healthcare provider of the finding immediately:
While it's important to communicate significant findings to the healthcare provider, the presence of Heberden's nodes in degenerative joint disease may not require immediate notification unless there are other concerning symptoms or complications.
D. Assess the client's radial pulses and capillary refill time:
Assessing radial pulses and capillary refill time is not directly related to managing Heberden's nodes in degenerative joint disease. These nodes are primarily a result of joint changes in osteoarthritis.
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