The client’s chart indicates the diagnosis of stage III peripheral arterial disease. Which nursing assessment finding correlates with this diagnosis?

Complaints of muscle cramps with exercise

Pedal pulses are +1 bilaterally

Complaints of burning pain during the night

Tissue that is blackened on the great toe

Answer and Explanation

The Correct Answer is C

Choice A rationale

Complaints of muscle cramps with exercise. While muscle cramps with exercise can be a symptom of peripheral arterial disease (PAD), they are more commonly associated with the earlier stages of the disease, known as intermittent claudication.

Choice B rationale

Pedal pulses are +1 bilaterally. Reduced or absent pedal pulses can be a sign of PAD, but a finding of +1 pedal pulses does not necessarily correlate with stage III of the disease.

Choice C rationale

Complaints of burning pain during the night. Stage III PAD, also known as critical limb ischemia, is characterized by more severe symptoms, including discomfort or pain in the feet or toes, even while at rest. Symptoms tend to worsen at night.

Choice D rationale

Tissue that is blackened on the great toe. This is a sign of gangrene, which is a severe and potentially life-threatening complication of PAD2. However, it is not a typical finding in stage III PAD, and would more likely be seen in the most advanced stage of the disease.

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Correct Answer is C

Explanation

Choice A rationale

Heparin does not actually thin the blood or make it less thick. Instead, it works by increasing the activity of antithrombin, a protein that inhibits blood clotting. This prevents new clots from forming and existing clots from growing larger.

Choice B rationale

Heparin does not dissolve clots or decrease the formation of platelets. Its primary action is to increase the activity of antithrombin, which in turn inactivates thrombin and factor Xa, two key players in the blood clotting process.

Choice C rationale

This statement is accurate. Heparin does not thin the blood; instead, it prevents new clots from forming and existing clots from growing larger. It does this by increasing the activity of antithrombin, which in turn inactivates thrombin and factor Xa.

Choice D rationale

Heparin does not decrease the number of platelets or make the blood flow more easily. Its primary action is to increase the activity of antithrombin, which in turn inactivates thrombin and factor Xa.

A. Administer morphine 2-4 mg IV prn for pain. B. Apply a figure of 8 pressure dressing starting day two post-operatively. C. Administer antibiotics as prescribed. D. Apply ice to the stump for 60-90 minutes.

Correct Answer is A

Explanation

The correct answer is Choice A. After a below-the-knee amputation (BKA), pain management is crucial. Administering morphine 2-4 mg IV prn for pain is an appropriate physician’s order to implement. Pain can be severe after amputation, and effective pain management can improve patient comfort, reduce anxiety, and aid in recovery. Applying a figure of 8 pressure dressing starting day two post-operatively (Choice B) is not typically done after a BKA7. The operative dressing and splint should be maintained, and the wound should be kept clean, dry, and intact. Administering antibiotics as prescribed (Choice C) is important, but it is not the first action to take. Pain management is the priority immediately after surgery. Applying ice to the stump for 60-90 minutes (Choice D) is not typically done after a BKA7. The operative dressing and splint should be maintained, and the wound should be kept clean, dry, and intact.

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The client’s chart indicates the diagnosis of stage III peripheral arterial disease. Which nursing assessment finding correlates with this diagnosis?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient diagnosed with deep vein thrombosis asks the nurse, “How does this blood thinner heparin work?” Which response is most accurate?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A client with diabetes has returned from the post-anesthesia care unit (PACU) after a below-the-knee amputation (BKA) of the left leg. Which physician’s order should the nurse implement?

Correct Answer is A

Explanation

The client newly diagnosed with Type 1 diabetes is to be discharged in the morning and has received no instruction on diabetes. What should be the nurse’s teaching priority?

A client diagnosed with peripheral arterial disease has the nursing problem of Impaired Tissue Integrity related to ischemic tissue of the legs and feet. What is an expected outcome to include in the care plan?

A patient diagnosed with diabetes has severe peripheral neuropathy resulting in numbness and reduced sensation of the feet. What intervention should the nurse teach the patient to prevent injury as a result of this complication?

A patient diagnosed with peripheral arterial disease is being educated about the benefits of walking for exercise. What information should the nurse emphasize?

A client is receiving heparin sodium 1000 units per hour via an infusion and warfarin sodium 2.5 mg PO for thrombophlebitis in the left leg. The nurse educates the client that heparin and warfarin are prescribed together because:

The nurse is discharging a client who was just prescribed insulin glargine daily at 2000. Which of the following should be included in the teaching? (SELECT ALL THAT APPLY)

A Type 1 diabetic client with a morning (fasting) glucose of 260 mg/dL has been diagnosed with the Somogyi effect from insulin administration. What intervention should the nurse anticipate including in the plan of care?