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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Clients taking clopidogrel should be advised to call their healthcare provider if they notice that their stools are dark. This could be a sign of gastrointestinal bleeding, a potential side effect of clopidogrel.

Choice B rationale

Changing positions slowly to avoid dizziness is not specifically related to clopidogrel use.

Choice C rationale

While it’s generally advised to avoid taking other blood thinners while on clopidogrel, aspirin is sometimes prescribed together with clopidogrel under the supervision of a healthcare provider.

Choice D rationale

There is no specific recommendation to take clopidogrel with orange juice for it to be more effective.

A. Administer the PRN antianxiety medication. B. Call the rapid response team. C. Increase the intravenous infusion rate. D. Prepare for mechanical ventilation.

Correct Answer is B

Explanation

Choice A rationale

Administering the PRN antianxiety medication is not the most appropriate next step. The client’s symptoms—shortness of breath, anxiety, restlessness, tachycardia, tachypnea, hypotension, and decreased oxygen saturation—are indicative of a potential pulmonary embolism, a life-threatening complication of deep vein thrombosis. While anxiety can be a symptom of a pulmonary embolism, treating it without addressing the underlying cause could delay necessary medical intervention.

Choice B rationale

Calling the rapid response team is the most appropriate next step. The client’s symptoms suggest a potential pulmonary embolism, a serious and life-threatening condition that requires immediate medical intervention. The rapid response team can provide the necessary urgent care.

Choice C rationale

Increasing the intravenous infusion rate is not the most appropriate next step. While hydration is important, it would not address the immediate life-threatening situation. The client’s symptoms suggest a potential pulmonary embolism, which requires immediate medical intervention.

Choice D rationale

Preparing for mechanical ventilation is not the most appropriate next step. While the client’s decreased oxygen saturation and increased respiratory rate suggest respiratory distress, the priority should be to address the potential pulmonary embolism. Mechanical ventilation may be necessary later depending on the client’s response to treatment.

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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?

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client diagnosed with peripheral arterial disease (PAD) has a new prescription for clopidogrel. What information should the nurse include when teaching the client about this medication?

Correct Answer is A

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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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?