The nurse notes the patient’s lower legs are brown and discolored and their feet are cold and slightly blue in color when in the dependent position. Which of the following actions should the nurse take?
Assist the patient to the chair for breakfast.
Check the presence of lower extremity pulses
Apply non-skid socks to feet
Perform deep tissue massage on bilateral lower extremities to improve blood flow.
The Correct Answer is B
A. Assist the patient to the chair for breakfast. Moving the patient to a chair may exacerbate venous stasis and worsen circulation in this case. This is not the correct action.
B. Check the presence of lower extremity pulses. Brown discoloration and cold, blue feet suggest poor circulation or chronic venous insufficiency. The nurse should assess the pulses to evaluate arterial blood flow in the lower extremities.
C. Apply non-skid socks to feet. While non-skid socks are generally used to prevent falls, this action does not address the circulatory concern indicated by the patient's symptoms.
D. Perform deep tissue massage on bilateral lower extremities to improve blood flow. Massage could be harmful, especially if there is a possibility of a blood clot or poor arterial circulation. This is not a recommended action in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.25"]
Explanation
Available dose: 0.125 mg tablets
Prescribed dose: 0.25 mg
To determine the number of tablets to administer:
Numberoftablets = Prescribeddose ÷ Availabledose
= 0.25 mg ÷0.125 mg
= 2 tablets
The nurse should administer 2 tablets of digoxin (0.125 mg each) to give the prescribed dose of 0.25 mg.
Correct Answer is D
Explanation
A. "A heart murmur is a high-pitched sound due to a narrow valve." While some murmurs may be caused by a narrow valve (stenosis), not all murmurs are high-pitched. Murmurs vary in pitch depending on the cause, so this is not a comprehensive explanation.
B. "A heart murmur is an extra sound your heart makes due to blood entering an inflexible chamber." This describes an S3 or S4 sound rather than a murmur. A heart murmur is typically related to turbulent blood flow through valves, not just an inflexible heart chamber.
C. "This means that there is some inflammation around your heart." This statement incorrectly links a murmur to pericarditis or myocarditis, which involve inflammation. A murmur is associated with abnormal blood flow, not inflammation.
D. "This indicates turbulent (chaotic, random fluctuations) blood flow through a valve." A heart murmur is caused by turbulent blood flow, which can occur when blood moves through a valve that is narrow or has regurgitation. This is the correct explanation.
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