A nurse is caring for a client with peripheral arterial disease (PAD). Which of the following interventions should the nurse include in the plan of care?

Encourage strict bed rest with tuning and repositioning every 2 hours.

Have the client dangle" their legs several times per day and when pain occurs,

Have the client elevate their legs above heart level when pain occurs

Have the client use ice packs to relieve lower extremity pain.

Answer and Explanation

The Correct Answer is B

A) "Encourage strict bed rest with turning and repositioning every 2 hours":
. For clients with peripheral arterial disease (PAD), strict bed rest is not recommended unless the client is in severe pain or experiencing complications like ulcers or gangrene. In PAD, exercise and mobility are essential for improving blood flow and reducing symptoms. Prolonged immobility could worsen circulation and lead to complications like muscle atrophy. Therefore, encouraging gentle movement and activity, like walking or repositioning, is typically more beneficial than prolonged bed rest.

B) "Have the client 'dangle' their legs several times per day and when pain occurs":
. For clients with PAD, dangling the legs can be helpful in alleviating pain and discomfort. When the client dangles their legs, gravity helps to increase blood flow to the lower extremities, which can provide temporary relief from symptoms like intermittent claudication (pain caused by insufficient blood flow). It is important to balance this with the advice to avoid elevating the legs, as elevating them above the heart level may decrease arterial perfusion, worsening symptoms.

C) "Have the client elevate their legs above heart level when pain occurs":
. Elevating the legs above the heart level in clients with PAD may worsen symptoms. In PAD, blood flow to the legs is already compromised, and elevating the legs above the heart can further reduce arterial blood flow to the lower extremities, increasing pain and discomfort. Instead, dangling the legs or lying flat with the legs at heart level is generally better for improving circulation.

D) "Have the client use ice packs to relieve lower extremity pain":
. Applying ice packs is not recommended for clients with PAD, as cold can cause vasoconstriction, further reducing blood flow to already compromised tissues. Cold therapy may increase pain and lead to tissue damage in individuals with reduced circulation. The nurse should instead focus on strategies that promote blood flow, such as encouraging gentle exercise, dangling the legs, or using warmth (in some cases) to improve circulation.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A) "The medication should be given with 5-6 hours of the onset of stroke symptoms":
. tPA (tissue plasminogen activator) is typically given for an ischemic stroke, and it is most effective when administered within 3 to 4.5 hours of the onset of stroke symptoms. After this time frame, the risk of bleeding complications increases, and the benefits of the medication diminish significantly. Giving tPA after 6 hours is generally considered outside the therapeutic window for ischemic stroke, though some centers may extend the window based on specific criteria.

B) "The medication is a primary treatment for hemorrhagic stroke":
. tPA is contraindicated in hemorrhagic stroke because it works by dissolving clots, which could worsen bleeding in the brain. Hemorrhagic stroke occurs when there is bleeding in the brain, and administering tPA would exacerbate the bleeding, leading to more severe brain injury and complications. The primary treatment for hemorrhagic stroke is controlling bleeding, often through surgical interventions or managing blood pressure.

C) "The medication can be given to prevent clot formation in the context of head trauma":
. tPA is not used to prevent clot formation, particularly in the setting of head trauma. It is used to dissolve existing clots in cases of ischemic stroke. Administering tPA after head trauma or brain injury could lead to catastrophic complications, such as worsening bleeding, and should be avoided. The use of tPA is contraindicated in trauma-related situations unless the stroke is clearly ischemic and there are no signs of hemorrhage.

D) "When given within a certain timeframe, the medication may dissolve an ischemic stroke":
. tPA is the standard treatment for ischemic strokes (caused by a clot blocking blood flow to the brain). When administered within 3 to 4.5 hours of the onset of symptoms, tPA can dissolve the clot, improving blood flow to the affected area of the brain and potentially minimizing the damage caused by the stroke. Timely administration is critical for maximizing its benefits in reducing disability and improving outcomes.

Correct Answer is ["50"]

Explanation

Given:

Desired dose: Phenytoin 250 mg

Available concentration: Phenytoin oral solution 25 mg/5 mL

To find:

Volume to administer per dose (in mL)

Step 1: Set up the proportion

We can use the following proportion to solve the problem:

(Desired dose) / (Available concentration) = Volume to administer

Step 2: Substitute the values

Plugging in the given values, we get:

(250 mg) / (25 mg/5 mL) = Volume to administer

Step 3: Simplify

To simplify, we can invert the denominator and multiply:

(250 mg) x (5 mL / 25 mg) = Volume to administer

The "mg" units cancel out, leaving us with:

(250 x 5 mL) / 25 = Volume to administer

Step 4: Calculate

Performing the multiplication and division, we get:

1250 mL / 25 = Volume to administer

50 mL = Volume to administer

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A nurse is caring for a client with peripheral arterial disease (PAD). Which of the following interventions should the nurse include in the plan of care?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is ["50"]

Explanation

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