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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Transesophageal echocardiography is a diagnostic procedure that involves inserting a probe into the esophagus to obtain detailed images of the heart. In some cases, an access line may be initiated in the femoral artery to monitor blood pressure during the procedure and administer medications if needed. Informing the client about this aspect of the procedure helps ensure that they are aware of what to expect and can provide informed consent.

Let's go through the other options and explain why they are not the most appropriate actions:

Instruct the client to drink 1 L of water before the test: This action is not necessary for transesophageal echocardiography. Drinking water before the test is typically done for certain abdominal or pelvic ultrasound examinations to provide better visualization. However, for TEE, the probe is inserted into the esophagus, and drinking water is not required.

Administer intravenous (IV) benzodiazepines and opioids: The administration of intravenous benzodiazepines and opioids is not a routine part of preparing a client for TEE. The need for sedation or analgesia during the procedure would be determined based on the individual client's condition and level of discomfort.

Inform the client that the client will remain on bed rest following the procedure: While some post-procedure instructions may be given to the client, such as avoiding eating or drinking until the effects of sedation wear off, informing the client that they will remain on bed rest following the procedure is not a speciﬁc requirement for TEE. Post-procedure instructions can vary depending on the individual client's condition and the healthcare provider's recommendations.

A. “I have stomach pain every time I eat a big, heavy meal." B. “I don't have any abdominal pain or any type of problems." C. “I have periodic episodes of constipation and then diarrhea." D. “I belch a lot especially when I lay down after eating"

Correct Answer is B

Explanation

Abdominal aortic aneurysms (AAA) often do not present with speciﬁc symptoms in the early stages. It is not uncommon for individuals with AAA to be asymptomatic or have vague symptoms. Therefore, the absence of abdominal pain or any problems related to the abdomen is a common ﬁnding during the assessment of a client with an abdominal aortic aneurysm.

Let's brieﬂy review the other statements:

"I have stomach pain every time I eat a big, heavy meal": This statement is more suggestive of gastrointestinal issues such as indigestion or acid reﬂux rather than speciﬁcally related to an abdominal aortic aneurysm.

"I have periodic episodes of constipation and then diarrhea": This statement may indicate gastrointestinal issues, but it is not a typical symptom associated with an abdominal aortic aneurysm. AAA is primarily related to the aorta, the main blood vessel in the abdomen, and its symptoms are not directly linked to bowel function.

"I belch a lot, especially when I lay down after eating": This statement suggests gastrointestinal symptoms such as acid reﬂux or gastroesophageal reﬂux disease (GERD). While these symptoms may be unrelated to the abdominal aortic aneurysm itself, they can coexist with other conditions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client for scheduled transesophageal echocardiography. Which action should the nurse perform?

Correct Answer is D

Explanation

The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment?

Correct Answer is B

Explanation

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The nurse is screening a client prior to an magnetic resonance imaging (MRI). What information is important to report to the health care provider before the MRI?

While assessing a client, the nurse notes that the client's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best follow up this assessment ﬁnding?

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A nurse is teaching a client with chronic peripheral artery disease. What client statement indicates the need for further teaching?

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