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 D

Explanation

A. While it is important to maintain a clean and dry dressing, changing it immediately may not be necessary at this stage. The small amount of bloody drainage could be a normal postoperative finding, and changing the dressing could disturb the surgical site.
B. While it is important to keep the physician informed of any changes, in this case, a small amount of bloody drainage may not warrant immediate notification unless it becomes excessive or is accompanied by other concerning symptoms.
C. Lowering the head of the bed might not directly address the situation. It may be more appropriate if the patient shows signs of hypotension or distress, but there is no indication that the drainage has caused such a concern at this moment.
D. Marking the area of drainage allows for proper monitoring of the situation. It helps track whether the drainage increases, remains the same, or decreases over time. Documentation of the time and date also provides a clear record for the healthcare team regarding the postoperative course, which is essential for ongoing assessment.

A. omitted meals. B. a GI disturbance. C. not taking insulin regularly. D. an insulin overdosage.

Correct Answer is C

Explanation

A. While skipping meals can affect blood glucose levels, it is not a direct primary cause of DKA. In some cases, if a person with Type 1 diabetes skips a meal and does not adjust their insulin accordingly, it could lead to hyperglycemia. However, the absence of insulin is the critical factor in DKA.
B. Gastrointestinal disturbances, such as vomiting or diarrhea, can contribute to DKA by leading to dehydration and altering insulin absorption. However, they are not primary causes. The main concern is that they may cause the individual to skip insulin or not manage their diabetes effectively.
C. DKA is primarily caused by a lack of insulin, which leads to the body breaking down fat for energy instead of glucose. This process produces ketones, which can accumulate and lead to acidosis. For individuals with Type 1 diabetes, consistently taking insulin is crucial to prevent DKA.
D. An insulin overdose can lead to hypoglycemia, not DKA. When too much insulin is taken, it can cause blood glucose levels to drop too low, which is the opposite of what occurs in DKA.

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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

Correct Answer is D

Explanation

The nurse is teaching an adult client with Type 1 diabetes that a primary cause of the development of diabetic ketoacidosis (DKA) is:

Correct Answer is C

Explanation

A client diagnosed with diabetes has severe peripheral neuropathy, resulting in numbness and reduced sensation. Which intervention should the nurse teach the client to prevent injury as a result of this complication?

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?

The nurse recognizes that teaching a client to wash the hands after using the bathroom is an attempt to break the chain of infection between the:

A client with Type 2 diabetes is brought into the emergency room in an unresponsive state. A diagnosis of Hyperosmolar Hyperglycemic Syndrome (HHS) is made. The nurse prepares for the administration of which initial therapy?

The client's chart indicates the diagnosis of stage III peripheral arterial disease. Which nursing assessment finding correlates with this diagnosis?

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:

A nurse is teaching a client with diabetes mellitus about chronic complications associated with the disease. Which information should be included in the teaching?