The nurse is caring for a client with a diagnosis of chronic peripheral arterial disease. Which statement by the client warrants immediate intervention by the nurse?

"I noticed that the hair on my feet and on my legs, is gone."

"My legs were so cold I had to put a heating pad on them."

"My legs start to hurt when I walk to get my mail."

"My feet look reddish when I put them down."

Answer and Explanation

The Correct Answer is B

A.   Loss of hair on the lower extremities can be a common sign of chronic PAD, indicating reduced blood
flow. While it’s an important observation, it is not an immediate concern.
B.   Cold legs can indicate poor blood flow, which is a significant concern in PAD. The use of a heating pad can pose a risk of burns due to impaired sensation, especially in clients with poor circulation. This statement warrants immediate intervention, as the nurse should educate the client against using heat sources that can cause injury and assess the client's circulation and potential complications.
C.   This describes claudication, a common symptom of PAD, where pain occurs in the legs due to inadequate blood flow during physical activity. While it indicates worsening symptoms of PAD, it is not an immediate emergency.
D.   Reddish discoloration (rubor) when the legs are dependent can indicate blood pooling due to decreased venous return or arterial insufficiency. While this observation is significant and requires monitoring, it is not as urgent as the concern related to using a heating pad.

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Correct Answer is D

Explanation

A. This time falls shortly after the onset of NPH insulin. While hypoglycemia could start to occur around this time, it is less likely to be at its peak.
B. This time is past the peak range of NPH insulin. The likelihood of hypoglycemia is lower as the insulin effect would be tapering off.
C. This time is well past the usual duration of NPH insulin. By this point, the risk of hypoglycemia would be significantly decreased.
D. This time falls within the peak action of NPH insulin (approximately 4-12 hours post-administration). This is when hypoglycemia is most likely to occur due to the greatest effect of the insulin.

A. Dextrose 5% 0.45% Normal Saline IV B. Oxygen by nasal cannula C. 0.9% saline solution IV D. Administration of Glucagon

Correct Answer is C

Explanation

A. While D5 0.45% NS contains dextrose, it is not suitable as an initial treatment in HHS because patients are often hyperglycemic. Starting with dextrose can worsen hyperglycemia.
B. Although providing oxygen may be appropriate if the client shows signs of respiratory distress or hypoxia, it is not the first-line treatment for HHS. The immediate priority is addressing dehydration and hyperglycemia.
C. The initial therapy for HHS involves administering IV fluids, typically starting with 0.9% saline (normal saline). This helps to rapidly rehydrate the client and dilute the high glucose levels in the blood. Correcting dehydration is critical in HHS management.
D. Glucagon is typically used to treat hypoglycemia, not hyperglycemia. In HHS, the patient is hyperglycemic, so administering glucagon would not be appropriate.

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The nurse is caring for a client with a diagnosis of chronic peripheral arterial disease. Which statement by the client warrants immediate intervention by the nurse?

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Naxlex Comprehensive Predictor Exams

A client receives 20 units of isophane insulin suspension (NPH) insulin at 0730. The nurse teaches the client that signs of hypoglycemia are most likely to occur at what time?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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