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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A ketogenic diet does not focus on high sodium or high sugar, as high sugar intake would increase carbohydrate levels.
B. A ketogenic diet is high in fat rather than low in fat.
C. High carbohydrates are avoided in a ketogenic diet, as the goal is to limit carbohydrates to promote ketone production.
D. The ketogenic diet consists of high fat and low carbohydrates, which helps to manage seizure activity by altering the brain's energy source to ketones rather than glucose.
Correct Answer is C
Explanation
A. While drug dependence can be a concern with long-term use, it is not the immediate priority in an emergency setting where the goal is to stabilize the patient in status epilepticus.
B. Cardiac rhythm monitoring is important when administering certain medications, but lorazepam primarily affects the central nervous system and respiratory system, making oxygen saturation monitoring more critical.
C. Pulse oximetry is the priority assessment as IV lorazepam can depress the respiratory system, leading to hypoxia. Monitoring oxygen saturation helps ensure the patient maintains adequate respiratory function during administration.
D. Assessing pain is important in patient care, but it is not the priority in managing a patient in status epilepticus, where stabilization is essential.
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