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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Elevate the head of the bed 45 degrees. The head of the bed should not be elevated this high, as this can increase pressure on the arterial access site, risking bleeding or disruption of the closure device.

B. Limit fluid intake for 4 hr after the procedure. Fluids should actually be encouraged to help flush out contrast dye used during the procedure and to maintain hydration. Limiting fluids could increase the risk of renal complications.

C. Have the client rest in bed for 2 hr. Bed rest is typically required after cardiac catheterization, especially with the use of an arterial closure device. Two hours is a reasonable time for initial bed rest following the procedure.

D. Insert an indwelling urinary catheter 1 hr post procedure. A urinary catheter is not routinely required after a cardiac catheterization unless there are specific medical indications.

A. Aim for a total cholesterol at 225 mg/dL. B. Maintain blood pressure at less than 140/90 mm Hg. C. Limit total fat intake to 50% of total daily calories. D. Keep body mass index (BMI) above 30.

Correct Answer is C

Explanation

A. Aim for a total cholesterol at 225 mg/dL. A total cholesterol level of 225 mg/dL is higher than the recommended target, which is typically less than 200 mg/dL. This is not an appropriate treatment goal.

B. Maintain blood pressure at less than 140/90 mm Hg. This is a reasonable goal for many clients with atherosclerosis. Keeping blood pressure below 140/90 mm Hg helps reduce the risk of further vascular damage.

C. Limit total fat intake to 50% of total daily calories. Limiting fat intake to 50% of total daily calories is excessive. The recommendation is usually around 25-35% of total daily calories from fat, with a focus on healthy fats.

D. Keep body mass index (BMI) above 30. A BMI above 30 is classified as obese, which is a risk factor for atherosclerosis. The goal is to reduce BMI to within a healthy range (18.5-24.9).

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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