A patient with peripheral arterial disease (PAD) is sitting in a chair and has cool feet that are reddish-purple in color. What action should the nurse take?
Notify the physician.
Evaluate the distal pulses.
Have the patient lie in bed with a pillow under the knees.
Cover the patient with a blanket.
The Correct Answer is B
Choice A reason: Notifying the physician is important, but it is not the immediate action to take. The nurse should first assess the patient's condition before contacting the physician.
Choice B reason: Evaluating the distal pulses is the correct action because it provides information on the blood flow to the extremities, which is crucial for patients with PAD.
Choice C reason: Having the patient lie in bed with a pillow under the knees is not recommended for PAD patients as it can decrease blood flow to the lower extremities.
Choice D reason: Covering the patient with a blanket may provide comfort, but it does not address the underlying issue of impaired blood flow in PAD.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Lying prone may be part of the care plan but is not specifically aimed at promoting ambulation.
Choice B reason: Coordination exercises are important but secondary to building the strength necessary for using mobility aids.
Choice C reason: Building upper body strength is essential for a patient who has had an above-the-knee amputation to be able to use assistive devices for ambulation effectively.
Choice D reason: Maintaining residual limb elevation is important for reducing swelling but does not directly promote ambulation.
Correct Answer is A
Explanation
Choice A reason: Informed consent is obtained when a patient agrees to a procedure after understanding its risks and benefits, which is what Melva provided.
Choice B reason: A time out is a final review before surgery to ensure correct patient identity, procedure, and site, which is not described here.
Choice C reason: Patient history refers to the collection of a patient's medical background, which is not the focus in this scenario.
Choice D reason: The pre-op checklist is a list of tasks to be completed before surgery, not a discussion of the procedure itself.
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