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 D
Explanation
Choice A reason: It is not recommended for clients to take morning vitamins before surgery due to the risk of aspiration and interference with anesthesia.
Choice B reason: Clients are typically instructed to remove all jewelry, including tongue studs, to prevent complications during surgery.
Choice C reason: Clients are generally required to fast before surgery, which includes not consuming clear liquids, to reduce the risk of aspiration.
Choice D reason: Allowing the client to keep her hearing aids in is important for communication and to reduce anxiety due to hearing impairment.
Correct Answer is D
Explanation
Choice A reason: Nurse self-awareness is crucial in providing care for individuals with personality disorders to avoid countertransference.
Choice B reason: Trust is a fundamental component of the nurse-client relationship and is necessary for effective care.
Choice C reason: Limit setting is essential for maintaining professional boundaries and providing structure in the therapeutic relationship.
Choice D reason: Vague communication is not therapeutic and can lead to misunderstandings and increased feelings of inferiority, which is not conducive to treatment.
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