The nurse is caring for a patient with a diagnosis of chronic peripheral arterial disease. Which statement by the patient warrants immediate intervention by the nurse?
“My feet look reddish when I put them down.”.
“I noticed that the hair on my feet and 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.”.
The Correct Answer is C
Choice A rationale
Reddish feet when put down could be a sign of dependent rubor, a condition that occurs due to peripheral arterial disease (PAD). When the legs are in a dependent (downward) position, gravity aids in delivering blood to the area, causing a reddish color. However, this is a common symptom of PAD and does not require immediate intervention.
Choice B rationale
Loss of hair on the feet and legs is another symptom of PAD1. This happens because inadequate blood flow deprives the hair follicles of the nutrients they need to grow. While this symptom indicates worsening PAD, it does not warrant immediate intervention.
Choice C rationale
Applying a heating pad to cold legs could lead to burns because PAD can cause loss of sensation in the legs. This warrants immediate intervention to prevent injury.
Choice D rationale
Leg pain during walking, also known as claudication, is a common symptom of PAD1. This happens because the muscles are not getting enough oxygen due to reduced blood flow.
However, this symptom does not require immediate intervention but should be evaluated further.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A. After a below-the-knee amputation (BKA), pain management is crucial. Administering morphine 2-4 mg IV prn for pain is an appropriate physician’s order to implement. Pain can be severe after amputation, and effective pain management can improve patient comfort, reduce anxiety, and aid in recovery. Applying a figure of 8 pressure dressing starting day two post-operatively (Choice B) is not typically done after a BKA7. The operative dressing and splint should be maintained, and the wound should be kept clean, dry, and intact. Administering antibiotics as prescribed (Choice C) is important, but it is not the first action to take. Pain management is the priority immediately after surgery. Applying ice to the stump for 60-90 minutes (Choice D) is not typically done after a BKA7. The operative dressing and splint should be maintained, and the wound should be kept clean, dry, and intact.
Correct Answer is B
Explanation
Choice A rationale
Drawing the peak level at 0930, which is 30 minutes after the start of the infusion, would be too early. The medication would not have had enough time to reach its peak level in the blood.
Choice B rationale
The peak level of gentamicin is typically evaluated 30 minutes after the completion of the infusion. Since the infusion is administered over 1 hour, the peak level would be expected to be drawn at 10001.
Choice C rationale
Drawing the peak level at 2030, which is 12 hours after the start of the infusion, would not provide an accurate representation of the peak level of gentamicin. This is because the medication would have been metabolized and excreted over this period.
Choice D rationale
Drawing the peak level at 2100, which is 12.5 hours after the start of the infusion, would not provide an accurate representation of the peak level of gentamicin. This is because the medication would have been metabolized and excreted over this period.
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