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 ["A","C"]
Explanation
A. Monitor your blood pressure on a regular basis: Regular monitoring of blood pressure is important for clients taking lisinopril to ensure the medication is effectively controlling hypertension.
B. Your cholesterol levels must be monitored monthly while taking this medication: Lisinopril does not typically require monthly cholesterol monitoring. This instruction is more relevant for statins or other lipid-lowering agents.
C. Report the development of a persistent dry cough.: A dry cough is a common side effect of ACE inhibitors like lisinopril. Clients should report this side effect as it may necessitate discontinuing the medication.
D. Your diet should include plenty of potassium-rich foods daily: Lisinopril can increase potassium levels, potentially causing hyperkalemia. Clients should be advised to avoid excessive potassium intake, not to increase it.
Correct Answer is D
Explanation
A. Valve disorder: While valve disorders can cause fatigue and dyspnea, the client’s history of hypertension, tachycardia, hypercholesteremia, and medication noncompliance are more suggestive of heart failure rather than a valve disorder.
B. Asthma: Asthma typically presents with wheezing, shortness of breath, and chest tightness. It is less likely to be the cause of symptoms in this scenario, where cardiac conditions and medication noncompliance are noted.
C. Pulmonary embolism: While pulmonary embolism can cause dyspnea and tachycardia, the client's chronic cardiovascular history and edema are more consistent with heart failure than an acute pulmonary embolism.
D. Heart failure: The client has a history of hypertension, tachycardia, and hypercholesteremia, along with medication noncompliance, tachycardia, and edema. These are classic signs of heart failure, making this the most likely diagnosis
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