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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Correct Answer is D

Explanation

A. 15-30g oral carbohydrates:
Oral carbohydrates are a first-line treatment for hypoglycemia in a conscious, alert patient who can safely swallow. However, since the patient is unresponsive, administering oral carbohydrates is not an appropriate option. The patient’s inability to swallow safely increases the risk of aspiration, making IV treatment the priority in this case.

B. 10% dextrose continuous IV infusion:
A 10% dextrose IV infusion can be used in the management of hypoglycemia, but in an acute, emergency setting where the patient is unresponsive and their blood glucose is critically low (30 mg/dL), a rapid-acting intervention is needed. A bolus dose of a concentrated solution, such as 50% dextrose, is more appropriate for quickly raising the blood glucose level in this situation, rather than a continuous infusion, which takes longer to achieve an effective increase in glucose.

C. Glucagon PO:
Glucagon is typically used for hypoglycemia in patients who are unconscious or unable to take oral glucose. However, glucagon is typically administered intramuscularly (IM) or subcutaneously (SQ), not orally (PO). Administering glucagon orally is ineffective, as it would not be absorbed by the body in the necessary manner to correct hypoglycemia. Therefore, this option is inappropriate.

D. 50% dextrose in water (50% DW) IV push:
When a patient is unresponsive and their blood glucose level is critically low (30 mg/dL), the priority treatment is an immediate, concentrated source of glucose. Administering 50% dextrose IV push is the most appropriate intervention in this scenario. It provides a rapid and effective increase in blood glucose levels, which is critical for reversing hypoglycemia in an emergency situation. This is the fastest and most direct approach to treating severe hypoglycemia in an unresponsive patient.

A. Have the client use the call light if they need to get up B. Pad the side rails of the client’s bed C. Ensure the lights in the room are as bright as possible at all times D. Avoid over stimulation and excessive activity in the client’s room

Correct Answer is C

Explanation

A. "Have the client use the call light if they need to get up":
This is an appropriate precaution to promote safety for a patient who has seizures. It is important to encourage patients to call for assistance before getting up, especially if they are at risk for seizures. Having the patient use the call light ensures that they do not try to walk or move without supervision, which could lead to falls or injury.

B. "Pad the side rails of the client’s bed":
This is also an appropriate precaution. Padding the side rails of the bed is a common safety measure for patients who are at risk for seizures. The padding helps prevent injury if the patient moves during a seizure. Side rails should be raised during a seizure to prevent the patient from falling out of bed, but the risk of injury from the side rails themselves is minimized with padding.

C. "Ensure the lights in the room are as bright as possible at all times":
This is not an appropriate precaution. Bright lights in the room could potentially cause overstimulation, which may be a trigger for seizures in some patients. In addition, bright lights could contribute to discomfort and anxiety. Instead, the room should be kept at a comfortable, calm lighting level to help reduce stress and minimize the risk of triggering a seizure.

D. "Avoid over stimulation and excessive activity in the client’s room":
This is an appropriate precaution. Avoiding overstimulation is important for patients with seizure disorders. Excessive noise, bright lights, or other sources of stress or agitation could provoke a seizure. A calm, quiet environment helps to promote safety and reduce the risk of a seizure occurring.

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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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Explanation

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