An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg, consistent with acute arterial occlusion.
After the nurse notifies the healthcare provider, what should the nurse do next?
Elevate the leg above the level of the heart.
Assist the patient in gently exercising the leg.
Apply a compression stocking to the leg.
Keep the patient in bed in the supine position.
The Correct Answer is D
Choice A rationale
Elevating the leg above the level of the heart would not be beneficial in this case. This action would actually reduce blood flow to the leg, which is already compromised due to the arterial occlusion.
Choice B rationale
Exercising the leg would increase the oxygen demand of the tissues in the leg, which could exacerbate the problem. The tissues in the leg are already deprived of oxygen due to the arterial occlusion.
Choice C rationale
Applying a compression stocking to the leg would not be beneficial in this case. This action would further compromise blood flow to the leg, which is already reduced due to the arterial occlusion.
Choice D rationale
Keeping the patient in bed in the supine position is the correct action. This position will decrease the oxygen demand of the tissues in the leg and minimize ischemic damage until circulation can be restored.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While calf tenderness and swelling after a plane ride could potentially indicate a deep vein thrombosis, this condition is not immediately life-threatening in most cases. The patient would need evaluation and treatment, but other patients might have more urgent needs14.
Choice B rationale
A patient taking anticoagulants for atrial fibrillation who has black stools could potentially have gastrointestinal bleeding, which would need evaluation. However, this condition might not be immediately life-threatening, and other patients might have more urgent needs14.
Choice C rationale
A patient with a gangrenous foot ulcer and a weak pedal pulse would need evaluation and treatment. However, this condition might not be immediately life-threatening, and other patients might have more urgent needs14.
Choice D rationale
A patient reporting sudden sharp and severe upper back pain could potentially have an aortic dissection, which is a life-threatening condition that requires immediate evaluation and treatment. Therefore, this patient should be assessed first14.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Advocating for a diet rich in saturated fats is not a recommended strategy to prevent cardiovascular disease. Saturated fats can raise the level of cholesterol in your blood and increase your risk of heart disease.
Choice B rationale
Recommending cessation of smoking is a crucial intervention to prevent cardiovascular disease. Chemicals in tobacco can damage the heart and blood vessels, leading to narrowing of the arteries (atherosclerosis), which can ultimately lead to a heart attack.
Choice C rationale
Regular blood pressure monitoring is important as high blood pressure is a significant risk factor for heart disease. Controlling blood pressure helps ensure that your heart is not working harder than it should be, which can prevent damage to your heart and arteries.
Choice D rationale
Regular cholesterol screenings are essential because high levels of cholesterol can lead to the buildup of plaques in your arteries, increasing your risk of heart disease.
Choice E rationale
Regular physical exercise helps control your weight and can reduce your chances of developing other conditions that may put a strain on your heart, such as high blood pressure, high cholesterol, and diabetes.
Choice F rationale
Suggesting no more than 5 alcoholic drinks a day is not a recommended strategy to prevent cardiovascular disease. In fact, it is advised to limit alcohol intake as excessive drinking can lead to high blood pressure, heart failure, or even stroke.
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