A nurse is developing home care instructions for a client with peripheral artery disease (PAD). Which intervention should the nurse include?

Rationale for Correct Choices

Option 1: Impaired gas exchange is the priority problem because the client's oxygen saturation is critically low at 88%, and the assessment reveals expiratory wheezes, rapid respirations (28/min), and severe shortness of breath. These indicate difficulty in maintaining adequate oxygenation.

Option 2: "I used my rescue inhaler three times, but I couldn’t catch my breath." This statement directly indicates that the asthma attack is unresponsive to the usual medication, highlighting the severity of the impaired gas exchange.

Rationale for Incorrect Choices

Option 1:

A. Anxiety: While anxiety may be present, it is a secondary issue caused by the asthma attack and is not the root cause of the client’s symptoms.

C. Ineffective airway clearance: Although wheezing suggests partial obstruction, the critical issue is the impaired oxygenation and low oxygen saturation rather than mucus or secretions obstructing the airway.

D. Activity intolerance: The client’s difficulty breathing is not primarily due to exertion but rather to the asthma attack itself.

Option 2:

A. "I was jogging when it started.": This identifies the trigger for the attack but does not explain the severity or lack of response to medication.

C. "My symptoms are worse when outdoors and when exercising.": This is helpful for identifying long-term triggers but does not prioritize the immediate issue of unrelieved shortness of breath.

D. "I noticed my inhaler was expired and was worried the medication was not working.": While this points to a lapse in medication management, it does not address the acute respiratory distress.

Choice A reason: While streaks of bright red blood in the stoma can be concerning, it is not necessarily an immediate emergency. It may indicate minor trauma or irritation, but it does not require immediate surgical intervention unless accompanied by other symptoms.

Choice B reason: The absence of bowel sounds in the left lower quadrant can indicate a lack of intestinal activity, which may be a concern, but it is not an immediate surgical emergency. It requires monitoring and further assessment.

Choice C reason: Brown, solid fecal matter is a normal finding and indicates that the colostomy is functioning properly. This is not a cause for immediate concern.

Choice D reason: The stoma mucosa being purple in color is a critical finding that requires immediate reporting to the surgeon. Purple stoma mucosa can indicate compromised blood flow or ischemia, which can lead to tissue necrosis and serious complications if not addressed promptly.