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 D
Explanation
Choice A rationale
Serum hemoglobin of 14.7 g/dL is within the normal range for adults, which is typically 12.0 to
16.0 g/dL for women and 13.5 to 17.5 g/dL for men. Hemoglobin is a protein in red blood cells that carries oxygen throughout the body. While it’s important to monitor hemoglobin levels, a value of 14.7 g/dL does not raise immediate concerns related to hypertension.
Choice B rationale
A blood glucose level of 96 mg/dL is considered normal. The normal range for fasting blood glucose is between 70 and 100 mg/dL1. Blood glucose levels are important to monitor, especially in patients with diabetes, but a value of 96 mg/dL is not immediately concerning in the context of hypertension.
Choice C rationale
A serum potassium level of 4.5 mEq/L is within the normal range, which is typically 3.6 to 5.2 mEq/L1. Potassium is an essential electrolyte that helps regulate heart and muscle contractions and maintain fluid balance in the body. While it’s important to monitor potassium levels, a value of 4.5 mEq/L does not raise immediate concerns related to hypertension.
Choice D rationale
A serum creatinine level of 2.8 mg/dL is high. Creatinine is a waste product that’s produced by your muscles and filtered out of your blood by your kidneys. High levels of creatinine can indicate that the kidneys aren’t working properly, which can be a complication of hypertension. Therefore, this result is the most important to communicate to the healthcare provider.
Correct Answer is A
Explanation
Choice A rationale
Clubbed fingers can be a symptom of conditions such as endocarditis, a heart condition that involves inflammation of the inner lining of the heart.
Choice B rationale
While myocardial infarction (heart attack) is a serious condition, it is not typically associated with clubbing of the fingers.
Choice C rationale
Acute kidney injury does not typically cause clubbing of the fingers.
Choice D rationale
Chronic thrombophlebitis, a condition characterized by inflammation and blood clots in the veins, is not typically associated with clubbing of the fingers.
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