A nurse is providing care for a patient who has weak pedal pulses, no hair on both legs, and a full-thickness wound on the right lateral malleolus with defined margins, which includes a small amount of serous exudate.
Which intervention should not be performed?
Evaluate the need for smoking cessation
Apply TED hose to both legs
Consult with physical therapy
Obtain Ankle-Brachial Index (ABI) using a hand-held Doppler
The Correct Answer is B
Choice A rationale
Evaluating the need for smoking cessation is a standard part of nursing care, especially for patients with circulatory issues. Smoking can exacerbate circulatory problems and delay wound healing.
Choice B rationale
Applying TED hose to both legs might not be appropriate for this patient. TED hose are compression stockings designed to prevent deep vein thrombosis and promote circulation. However, in a patient with weak pedal pulses and a full-thickness wound on the leg, the compression from the stockings could potentially worsen circulation to the area and impede wound healing.
Choice C rationale
Consulting with physical therapy could be beneficial for this patient. Physical therapists can provide exercises and interventions to improve circulation and mobility, which could help with the patient’s circulatory issues and wound healing.
Choice D rationale
Obtaining an Ankle-Brachial Index (ABI) using a hand-held Doppler could be useful in this situation. The ABI is a simple, non-invasive test that can help diagnose peripheral artery disease (PAD), a condition that could be causing the patient’s weak pedal pulses and wound healing issues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Administering Ibuprofen as scheduled is a proper nursing intervention for a patient with pericarditis. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can help reduce inflammation and relieve pain.
Choice B rationale
Monitoring the patient for complications of cardiac tamponade is a proper nursing intervention for a patient with pericarditis. Cardiac tamponade is a serious condition that can occur as a complication of pericarditis.
Choice C rationale
Placing the patient in a supine position to relieve pain is not a proper nursing intervention for a patient with pericarditis. This position could actually increase the patient’s discomfort.
Instead, the patient should be positioned upright and leaning forward to help relieve pain.
Choice D rationale
Monitoring the patient for pulsus paradoxus and muffled heart sounds is a proper nursing intervention for a patient with pericarditis. These are potential signs of worsening pericarditis or complications such as cardiac tamponade.
Correct Answer is D
Explanation
Choice A rationale
Exercise electrocardiography, also known as a stress test, is not typically the first-line emergent procedure for a patient with an acute myocardial infarction (AMI). This test is often used to diagnose coronary artery disease, but it is not typically used to treat an AMI5.
Choice B rationale
A computed tomography (CT) scan of the chest with contrast could be used to visualize the heart and surrounding structures, but it is not typically the first-line emergent procedure for a patient with an AMI5.
Choice C rationale
An echocardiogram could be used to visualize the heart’s structure and function, but it is not typically the first-line emergent procedure for a patient with an AMI5.
Choice D rationale
Percutaneous coronary intervention (PCI) is the correct answer. This procedure is often used as an emergent treatment for an AMI. It involves using a catheter to place a small structure called a stent to open up blood vessels in the heart that have been narrowed by plaque buildup.
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