The nurse is assessing a client with a presumptive diagnosis of peripheral arterial disease. The nurse obtains an Ankle-Brachial index of 0.89. Which intervention should the nurse take next?
Document the information as a normal finding
Prepare the client for an arterial bypass
Educate the client about the use of compression stocking
Anticipate a prescription for clopidogrel and simvastatin
The Correct Answer is D
An ABI of 0.89 indicates a reduced blood flow to the lower extremities, which is suggestive of peripheral arterial disease (PAD). In PAD, there is narrowing or blockage of the arteries that supply blood to the legs and feet. Medications like clopidogrel and simvastatin are commonly prescribed for individuals with PAD to manage the condition and reduce the risk of complications.
Here's an explanation of why the other options are not the most appropriate interventions:
Document the information as a normal finding: An ABI of 0.89 is not considered a normal finding. An ABI value below 0.9 is generally indicative of PAD or reduced blood flow to the lower extremities.
Prepare the client for an arterial bypass: An ABI value of 0.89 alone does not warrant immediate preparation for an arterial bypass. Arterial bypass surgery is typically considered for severe cases of PAD with significant symptoms that significantly impact the client's quality of life and other conservative treatments have not been successful.
Educate the client about the use of compression stockings: While compression stockings may be a part of the overall management of PAD, the ABI result alone does not indicate an immediate need for education about compression stockings. Other interventions, such as medication management, lifestyle modifications, and possibly revascularization procedures, may be more appropriate based on the severity of the PAD.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The most appropriate nursing intervention to improve adhesion of the ECG leads on a male client with abundant chest hair is to clip the chest hair with the patient's permission before applying the leads. Chest hair can interfere with the adhesion of the ECG leads, resulting in poor signal quality and potentially affecting the accuracy of the ECG recording. By clipping the chest hair, the nurse can improve the contact between the skin and the ECG leads, allowing for better adhesion and signal transmission.
It is important to obtain the patient's permission before clipping the chest hair to respect their autonomy and ensure their comfort during the procedure. The nurse should explain the reason for clipping the hair and address any concerns or questions the patient may have.
Let's review the other options and explain why they are not the most appropriate interventions:
Using alcohol swabs to clean the skin before applying the leads: While cleaning the skin with alcohol swabs is a routine practice to remove oils and dirt that can affect adhesion, it may not be sufficient in the presence of abundant chest hair. Clipping the hair would be more effective in this situation.
Applying the leads to the arms and legs only: This option would not provide an accurate 12-lead ECG recording, as the chest leads are essential for evaluating the electrical activity of the heart from different angles. It is important to have the leads properly placed on the chest for an accurate assessment.
Rescheduling the ECG: Unless there are other valid reasons for rescheduling, such as a medical condition that contraindicates the procedure, rescheduling solely due to abundant chest hair would be unnecessary. Clipping the hair is a practical and effective solution to improve adhesion.
Correct Answer is A
Explanation
The nurse should teach the client that the transthoracic echocardiography is a noninvasive test and that nothing will be inserted into the client's body.
Transthoracic echocardiography is a diagnostic procedure that uses ultrasound to create images of the heart's structures and assess its function. It is a noninvasive test, meaning that it does not involve any insertion of instruments or devices into the body. Instead, a transducer is placed on the chest to obtain images of the heart.
The statement about managing pain aggressively during the procedure is not applicable to transthoracic echocardiography. It is generally a painless procedure that does not cause discomfort.
Transthoracic echocardiography primarily provides detailed images of the heart's structures and function, such as the chambers, valves, and pumping action. It does not specifically profile the heart's electrical activity, which is usually assessed using an electrocardiogram (ECG) or other specialized tests.
Regarding bed rest after the test, there is typically no need for bed rest following transthoracic echocardiography. The client can usually resume normal activities immediately after the procedure. However, the nurse should provide specific instructions based on the client's condition and any additional tests or interventions planned.
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