The nurse is assessing a client who was admitted yesterday with peripheral artery disease (PAD) and an ulcer on the lateral malleolus. Which finding is most important for the nurse to report to the healthcare provider?
Pain in lower legs when walking.
Black eschar over ankle ulcer.
Absent pedal pulses by Doppler.
Dependent rubor of lower extremities.
The Correct Answer is C
Choice A reason: Pain in the lower legs when walking, also known as intermittent claudication, is a common symptom of PAD but does not indicate an immediate threat to limb viability.
Choice B reason: Black eschar over the ankle ulcer indicates necrotic tissue, which is concerning but not as immediately critical as absent pulses. It does need to be monitored and treated to prevent infection and further complications.
Choice C reason: Absent pedal pulses by Doppler indicate a significant reduction in blood flow to the lower extremities, which can lead to critical limb ischemia and requires immediate intervention to restore perfusion and prevent tissue loss.
Choice D reason: Dependent rubor (redness when the leg is in a dependent position) is a sign of poor arterial circulation but does not require as urgent intervention as absent pedal pulses.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Applying drying agents on draining lesions every day is not recommended for clients with SLE. This approach can lead to excessive dryness and irritation of the skin, which can worsen the condition and cause additional discomfort. Moisturizing and protecting the skin are more appropriate measures.
Choice B reason: While avoiding contact with others can help prevent the spread of infections, it is not the most important aspect of skin care for SLE. SLE is an autoimmune condition, and managing skin care focuses more on protecting the skin from external triggers and minimizing inflammation.
Choice C reason: Tanning booths are not safe for clients with SLE. Exposure to UV light, whether from the sun or artificial sources, can exacerbate SLE symptoms and trigger flares. Therefore, it is important to avoid both direct sunlight and tanning booths.
Choice D reason: Using a very strong sunblock when out in the sun is crucial for clients with SLE. Sun exposure can worsen skin lesions and trigger flares, so it is essential to protect the skin with a high SPF sunblock, wear protective clothing, and seek shade whenever possible.
Correct Answer is A
Explanation
Choice A reason: Elevating the head of the bed to 90 degrees is crucial for clients in respiratory distress. This position helps to maximize lung expansion, improve breathing, and alleviate respiratory effort. It provides immediate support to enhance oxygenation and ventilation.
Choice B reason: Monitoring pulse oximetry is important for assessing the client's oxygenation status but should be done continuously rather than every 2 hours in a client in respiratory distress.
Choice C reason: Determining exposure to asthmatic triggers is relevant for long-term management but not the immediate priority in an acute situation where the client is in respiratory distress.
Choice D reason: Teaching the proper use of a rescue inhaler is essential but should be done after stabilizing the client's condition. The immediate focus should be on interventions that provide rapid relief from respiratory distress.
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