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. Altered mental status, such as confusion, restlessness, or lethargy, is often the earliest sign of increasing ICP as it reflects brain tissue compression.

B. Tachycardia and hypotension are not primary indicators of elevated ICP.

C. Fixed and dilated pupils indicate severe and often irreversible ICP increase, occurring later in the progression.

D. Widening pulse pressure is a later sign of increased ICP, following changes in mental status.

A. Remove all foreign objects B. Stabilize object and lightly protect with covering C. Provide a light meal with clear liquids D. Instruct the patient vigorously blow their nose if necessary

Correct Answer is B

Explanation

A. Removing objects is contraindicated, as it can worsen the injury.

B. Stabilizing the object and covering it prevents further injury until medical evaluation, which is critical in cases of eye trauma. Moving or removing a foreign body could lead to additional damage.

C. Providing a light meal is not directly related to managing eye trauma and does not address the immediate concern.

D. Blowing the nose could increase intraocular pressure, potentially worsening the injury.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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