A patient has returned to the unit following a peripheral arteriogram. During the assessment, the nurse notes that the dorsalis pedis pulse is not palpable and the foot is cold. What should be the nurse's immediate action?

Notify the physician of this finding

Elevate the limb on two pillows

Cover the limb with a blanket

Reposition the limb and reassess

Answer and Explanation

The Correct Answer is A

A. A cold, pulseless foot indicates compromised blood flow, a medical emergency following an arteriogram. The nurse should immediately notify the physician to address potential vascular occlusion.

B. Elevating the limb can further impair circulation if blood flow is already compromised.

C. Covering the limb will not address the underlying issue of impaired circulation.

D. Repositioning may delay timely intervention in what may be a vascular emergency.

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Correct Answer is A

Explanation

A. Elevating the head of the bed, loosening clothing, and checking for urinary catheter obstruction are key steps to lower blood pressure and relieve triggers of autonomic dysreflexia, a potentially life-threatening condition.

B. A cool compress may provide comfort but does not directly address the primary triggers or symptoms of autonomic dysreflexia.

C. Semi-Fowler's position is insufficient compared to a full 90-degree sitting position, which helps reduce blood pressure.

D. IV access and oxygen may be required if symptoms do not resolve, but immediate actions focus on relieving the cause of dysreflexia.

A. Scheduled voiding B. Intermittent catheterization C. Indwelling urinary catheter D. External catheter

Correct Answer is B

Explanation

A. Scheduled voiding is less effective in patients with a flaccid bladder because there is no voluntary control of bladder function.

B. Intermittent catheterization is the preferred management technique for a flaccid or atonic bladder, allowing the bladder to empty at regular intervals and reducing the risk of infection associated with continuous catheters.

C. An indwelling catheter is usually avoided for long-term use due to a higher risk of infection.

D. An external catheter is generally not effective for flaccid or atonic bladder management in spinal cord injuries as it doesn’t actively empty the bladder.

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A patient has returned to the unit following a peripheral arteriogram. During the assessment, the nurse notes that the dorsalis pedis pulse is not palpable and the foot is cold. What should be the nurse's immediate action?

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Naxlex Comprehensive Predictor Exams

The nurse suspects autonomic dysreflexia in the patient with a spinal cord injury at the level of C-7. After checking vital signs what are the priority nursing interventions?

Correct Answer is A

Explanation

The nurse is caring for a patient with a spinal cord injury who has a flaccid or atonic bladder. The nurse would provide discharge education to the patient and family regarding which bladder management technique?

Correct Answer is B

Explanation

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