The nurse is caring for a client with weak pedal pulses, absent hair on bilateral legs, and a full-thickness wound on the right lateral malleolus with defined margins, including a minimal amount of serous exudate.

Which of the following interventions is contraindicated?

Assess the need for smoking cessation.

Apply TED hose to bilateral legs.

Consult physical therapy.

Obtain Ankle-Brachial Index (ABI) with a hand-held Doppler.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Assessing the need for smoking cessation is a standard part of nursing care, especially for patients with circulatory issues. Smoking can exacerbate circulatory problems and delay wound healing.
Choice B rationale
Applying TED hose to bilateral legs might not be appropriate for this patient. TED hose are compression stockings designed to prevent deep vein thrombosis and promote circulation.
However, in a patient with weak pedal pulses and a full-thickness wound on the leg, the compression from the stockings could potentially worsen circulation to the area and impede wound healing.
Choice C rationale
Consulting physical therapy could be beneficial for this patient. Physical therapists can provide exercises and interventions to improve circulation and mobility, which could help with the patient’s circulatory issues and wound healing.
Choice D rationale
Obtaining an Ankle-Brachial Index (ABI) with a hand-held Doppler could be useful in this situation. The ABI is a simple, non-invasive test that can help diagnose peripheral artery disease (PAD), a condition that could be causing the patient’s weak pedal pulses and wound healing issues.

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Correct Answer is D

Explanation

Choice A rationale
Increasing glomerular filtration would result in increased urine output, not decreased venous return. This action is not directly related to the therapeutic action of nitroglycerin.
Choice B rationale
While enhancing the contractility of the myocardium would increase oxygen delivery, this is not the primary action of nitroglycerin. Nitroglycerin primarily works by dilating the blood vessels, which reduces the amount of work the heart has to do and increases the blood supply to the heart muscle.
Choice C rationale
Nitroglycerin does not produce an immediate analgesic effect. While it can relieve chest pain, it does so by increasing blood flow to the heart, not by acting as an analgesic.
Choice D rationale
Nitroglycerin increases the coronary blood supply and decreases the afterload314. By dilating the blood vessels, nitroglycerin reduces the amount of work the heart has to do and increases the blood supply to the heart muscle. This is the primary therapeutic action of nitroglycerin in alleviating chest pain.

A. Ulceration on the medial surface of the lower legs. B. Brownish skin discoloration on the lower legs. C. Edema in the lower legs. D. Purple rash on the medial surface of the lower legs.

Correct Answer is B

Explanation

Choice A rationale
Ulceration on the medial surface of the lower legs is not the best description of stasis dermatitis in a patient with peripheral vascular disease (PVD). While ulcers can occur in severe cases, they are not the primary characteristic of stasis dermatitis.
Choice B rationale
Stasis dermatitis, also known as venous stasis dermatitis, is a skin inflammation that occurs in people with poor circulation. It most often happens in the lower legs because that’s where blood typically collects. When blood pools in the veins of the lower leg, it can cause a variety of symptoms, including a brownish skin discoloration on the lower legs. This discoloration is caused by the leakage of red blood cells into the skin due to increased pressure in the veins.
Choice C rationale
While edema in the lower legs can be a symptom of PVD and may accompany stasis dermatitis, it is not the best description of the condition. Edema is a general symptom that can occur in many conditions and is not specific to stasis dermatitis.
Choice D rationale
A purple rash on the medial surface of the lower legs is not a typical symptom of stasis dermatitis. While the skin may become discolored, it is usually a brownish color rather than purple.

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The nurse is caring for a client with weak pedal pulses, absent hair on bilateral legs, and a full-thickness wound on the right lateral malleolus with defined margins, including a minimal amount of serous exudate. Which of the following interventions is contraindicated?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is administering nitroglycerin intravenously to alleviate chest pain. What is the therapeutic action of this medication?

Correct Answer is D

Explanation

How would a nurse best describe the assessment of stasis dermatitis in a patient with peripheral vascular disease (PVD)?

Correct Answer is B

Explanation

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The nurse is caring for a client with weak pedal pulses, absent hair on bilateral legs, and a full-thickness wound on the right lateral malleolus with defined margins, including a minimal amount of serous exudate.

Which of the following interventions is contraindicated?