The nurse is assessing a client who was admitted yesterday with peripheral artery disease (PAD) and an ulcer on the lateral malleolus. Which finding is most important for the nurse to report to the healthcare provider?

Pain in lower legs when walking.

Black eschar over ankle ulcer.

Absent pedal pulses by Doppler.

Dependent rubor of lower extremities.

Answer and Explanation

The Correct Answer is C

Choice A reason: Pain in the lower legs when walking, also known as intermittent claudication, is a common symptom of PAD but does not indicate an immediate threat to limb viability.

Choice B reason: Black eschar over the ankle ulcer indicates necrotic tissue, which is concerning but not as immediately critical as absent pulses. It does need to be monitored and treated to prevent infection and further complications.

Choice C reason: Absent pedal pulses by Doppler indicate a significant reduction in blood flow to the lower extremities, which can lead to critical limb ischemia and requires immediate intervention to restore perfusion and prevent tissue loss.

Choice D reason: Dependent rubor (redness when the leg is in a dependent position) is a sign of poor arterial circulation but does not require as urgent intervention as absent pedal pulses.

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Correct Answer is C

Explanation

Choice A reason: Lung sounds are important to assess for signs of fluid in the lungs, such as crackles, which can occur with fluid volume overload. However, they do not directly measure fluid balance.

Choice B reason: Turgor assesses skin elasticity and hydration status, but it is not the most accurate indicator of overall fluid balance in the context of fluid volume overload.

Choice C reason: Weight is the most accurate and direct measure of fluid balance. Daily weight monitoring can track changes in fluid status, as weight fluctuations can reflect gains or losses in body fluid.

Choice D reason: Blood pressure is important to monitor, especially in clients with fluid volume issues, but it is not the most direct measure of fluid balance. Weight changes provide more precise information about fluid status.

A. Cold intolerance. B. Weight gain. C. Hypoventilation. D. Lethargy.

Correct Answer is C

Explanation

Choice A reason: Cold intolerance is a common symptom of hypothyroidism due to the reduced metabolic rate. While it is important to address this symptom, it does not require immediate intervention compared to respiratory issues.

Choice B reason: Weight gain is also a common symptom of hypothyroidism because of the decreased metabolism. It is significant but not immediately life-threatening, so it does not take priority over more urgent conditions.

Choice C reason: Hypoventilation is the most critical finding because it indicates respiratory depression. This can lead to severe hypoxia and carbon dioxide retention, potentially causing life-threatening complications. Immediate intervention is required to support the client's breathing and prevent respiratory failure.

Choice D reason: Lethargy is a common symptom of hypothyroidism due to the overall slowing of the body's functions. While concerning, it is not as immediately dangerous as hypoventilation, which directly affects the client's ability to breathe effectively.

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The nurse is assessing a client who was admitted yesterday with peripheral artery disease (PAD) and an ulcer on the lateral malleolus. Which finding is most important for the nurse to report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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