A client has returned to the unit following a peripheral angiogram with a stent insertion. Four hours post procedure, the nurse can no longer palpate the dorsalis pedis pulse and the foot is cool and dusky. What should be the nurse's immediate action?

Notify the physician

Cover the limb with a blanket

Reposition the limb and reassess

Elevate the extremity on a pillow

Answer and Explanation

The Correct Answer is A

A.   The loss of a pulse and the cool, dusky appearance of the foot indicate potential complications such as thrombus formation or arterial occlusion, which require prompt medical evaluation and intervention. Notifying the physician ensures that appropriate diagnostic and therapeutic measures can be taken quickly.
B.   While keeping the client warm is important, simply covering the limb does not address the underlying issue of compromised circulation. This action could potentially delay necessary interventions that address the lack of blood flow.
C.   Although repositioning the limb might help with circulation, it is not sufficient given the critical nature of the symptoms. It is essential to first inform the physician to get guidance on further evaluation or interventions. Repositioning could also delay timely intervention needed to prevent tissue damage.
D.   Elevating the limb might worsen blood flow in a case of compromised circulation. In cases of suspected arterial occlusion, keeping the limb at heart level or below may be more appropriate to promote blood flow. Elevating it could delay necessary treatment.

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Correct Answer is ["C","D","E"]

Explanation

A. Clients on warfarin should generally avoid nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin and ibuprofen, as these can increase the risk of bleeding. Instead, acetaminophen is often recommended for pain relief, but it should be used cautiously and under a healthcare provider’s guidance.
B. While vitamin K found in green, leafy vegetables can affect warfarin levels, clients do not need to eliminate these foods entirely. Instead, they should maintain a consistent intake of vitamin K-rich foods to help manage their INR levels. Sudden changes in diet can lead to fluctuations in anticoagulation control.
C. It is important for clients taking warfarin to wear a medical alert bracelet. This alerts healthcare providers in case of an emergency, as the client may require special care due to their anticoagulant therapy.

D. Using an electric razor is a safer option for clients on warfarin as it reduces the risk of cuts and bleeding compared to using a traditional razor. This is an important safety measure for those on anticoagulation therapy.
E. Monitoring prothrombin time (PT) and International Normalized Ratio (INR) is essential for clients on warfarin to ensure they are within the therapeutic range. Regular testing helps to manage the dosage effectively and minimize the risk of bleeding or thrombosis.

A. 2 to 4 hours. B. 12 to 16 hours. C. 3 to 10 hours. D. 2 to 8 hours.

Correct Answer is A

Explanation

This is the expected peak time for regular insulin. After administration, the insulin will generally reach its maximum effectiveness in lowering blood glucose within this timeframe, making it essential for the client to monitor their blood sugar levels accordingly.

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A client has returned to the unit following a peripheral angiogram with a stent insertion. Four hours post procedure, the nurse can no longer palpate the dorsalis pedis pulse and the foot is cool and dusky. What should be the nurse's immediate action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing teaching to a client who is being discharged with a prescription for warfarin. Which information should be included in the teaching for this medication? (SELECT ALL THAT APPLY)

Correct Answer is ["C","D","E"]

Explanation

A client's insulin dosage is 16 units of regular insulin in the morning. The client should be taught to expect the insulin peak within:

Correct Answer is A

Explanation

The client newly diagnosed with insulin dependent diabetes is to be discharged in the morning and has received no instruction on diabetes. The nurse's teaching priority is to instruct the client in:

A client with an above the knee amputation asks the nurse why the stump needs to be wrapped with an elastic bandage. The nurse explains that it:

A client has returned to the unit following a peripheral angiogram with a stent insertion. Four hours post procedure, the nurse can no longer palpate the dorsalis pedis pulse and the foot is cool and dusky. What should be the nurse's immediate action?

Which observation by the nurse indicates that a male client diagnosed with kidney stones is experiencing renal colic?

The nurse is caring for a client who is three hours postoperative left leg below the knee amputation (BKA). The client tells the nurse. "My left foot is killing me. Please do something!" Which intervention should the nurse implement?

The nurse is discharging a client who was just prescribed insulin glargine daily at 2100. Which of the following should be included in the teaching? (SELECT ALL THAT APPLY)

The nurse must give 25 micrograms of fentanyl IVP X 1 dose. Fentanyl is available in an ampule 100 micrograms per 2mL. How many mL will the nurse give for the correct dose? round to the nearest tenth. Use a preceding zero if necessary. Do not use trailing zeros.

A client with a deep vein thrombosis has been receiving warfarin sodium 2.5 mg PO daily. The client's International Normalized Ratio (INR) is 5.0. The nurse is aware that the medication dose needs to be: