A patient has returned to the unit following a peripheral artery angiogram with a stent insertion.
Four hours post-procedure, the nurse can no longer palpate the dorsalis pedis pulse and the foot is cold and dusky. What should be the nurse’s immediate action?
Reposition the limb and reassess.
Apply a warm blanket.
Notify the healthcare provider.
Elevate the extremity on a pillow.
The Correct Answer is C
Choice A rationale
While repositioning the limb and reassessing might be a part of the overall evaluation, it should not be the immediate action. The symptoms described are indicative of a serious issue that requires immediate medical attention.
Choice B rationale
Applying a warm blanket will not address the underlying issue. The symptoms described suggest a problem with circulation that needs immediate medical attention.
Choice C rationale
Notifying the healthcare provider is the correct immediate action. The symptoms described suggest that the patient may be experiencing a complication such as occlusion of the stent. This is a medical emergency that requires immediate intervention.
Choice D rationale
Elevating the extremity on a pillow is not the immediate action to take. While elevation can help with conditions like edema, it does not address the serious symptoms the patient is experiencing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Acarbose and repaglinide are medications used to manage blood glucose levels in people with type 2 diabetes. Acarbose slows the digestion of carbohydrates in the gut, which helps to prevent spikes in blood glucose after meals. Repaglinide stimulates the pancreas to release more insulin. Both of these medications can cause hypoglycemia, or low blood sugar.
Therefore, carrying glucose tablets or gels is a good practice because they can quickly raise blood sugar levels during an episode of hypoglycemia.
Choice B rationale
Taking these medications on an empty stomach is not recommended. Acarbose should be taken with the first bite of each main meal. Repaglinide should be taken within 30 minutes before meals. Therefore, this statement does not indicate effective teaching.
Choice C rationale
Drinking orange soda to treat symptoms of hypoglycemia is not the best choice. While orange soda can increase blood sugar levels, it also contains other ingredients, like caffeine, that are not beneficial for people with diabetes. Glucose tablets or gels are a better option because they provide a fast-acting source of glucose and are easy to dose.
Choice D rationale
This statement is incorrect. While repaglinide does stimulate the pancreas to release more insulin, it does not mean that the person has to start taking insulin shots. Acarbose works by slowing the digestion of carbohydrates in the gut, not by affecting insulin release. Therefore, this statement does not indicate effective teaching.
Correct Answer is A
Explanation
Choice A rationale
Intermittent claudication, which involves limb pain or cramping that generally begins when exercising and improves while resting, is a common symptom in the early stages of PAD5.
Choice B rationale
Foot ulcers are not typically a symptom of the early stages of PAD. They are more likely to occur in the later stages of the disease when blood flow to the extremities is significantly reduced.
Choice C rationale
Pain at rest is not typically a symptom of the early stages of PAD. It is more likely to occur in the later stages of the disease when blood flow to the extremities is significantly reduced.
Choice D rationale
Dependent rubor is not typically a symptom of the early stages of PAD. It is more likely to occur in the later stages of the disease when blood flow to the extremities is significantly reduced.
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