The nurse notes the patient’s lower legs are brown and discolored and their feet are cold and slightly blue in color when in the dependent position. Which of the following actions should the nurse take?

Assist the patient to the chair for breakfast.

Check the presence of lower extremity pulses

Apply non-skid socks to feet

Perform deep tissue massage on bilateral lower extremities to improve blood flow.

Answer and Explanation

The Correct Answer is B

A. Assist the patient to the chair for breakfast. Moving the patient to a chair may exacerbate venous stasis and worsen circulation in this case. This is not the correct action.

B. Check the presence of lower extremity pulses. Brown discoloration and cold, blue feet suggest poor circulation or chronic venous insufficiency. The nurse should assess the pulses to evaluate arterial blood flow in the lower extremities.

C. Apply non-skid socks to feet. While non-skid socks are generally used to prevent falls, this action does not address the circulatory concern indicated by the patient's symptoms.

D. Perform deep tissue massage on bilateral lower extremities to improve blood flow. Massage could be harmful, especially if there is a possibility of a blood clot or poor arterial circulation. This is not a recommended action in this scenario.

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Correct Answer is B

Explanation

A. "I can eat frozen juice bars for a snack." Frozen juice bars are generally low in sodium and are a healthy snack option for clients with hypertension. This choice is acceptable as long as they are made from 100% juice and do not contain added sugars or sodium.

B. "I can have a cola drink twice a day." Cola drinks contain caffeine, sugar, and sometimes sodium, which can increase blood pressure. Clients with hypertension should limit their intake of sugary or caffeinated drinks. This statement indicates a need for further teaching.

C. "I will replace table salt with dried herbs." Replacing table salt with dried herbs is a good practice to reduce sodium intake, which can help manage hypertension. This statement does not indicate a need for further teaching.

D. "Fresh fruits are good to include with meals." Fresh fruits are low in sodium and rich in potassium, which can help regulate blood pressure. This is a good dietary choice for clients with hypertension and does not indicate a need for further teaching.

A. Popliteal B. Brachial C. Femoral D. Carotid

Correct Answer is D

Explanation

A. Popliteal: Checking the popliteal pulse bilaterally is generally safe, as it does not carry the risk of compromising blood flow to the brain.

B. Brachial: Checking the brachial pulse bilaterally is safe and does not compromise circulation to vital organs.

C. Femoral: The femoral pulse can be checked bilaterally without causing significant issues.

D. Carotid: Checking the carotid pulse bilaterally can reduce blood flow to the brain and lead to syncope (fainting), so it should be avoided. Palpating one carotid artery at a time is the correct approach.

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The nurse notes the patient’s lower legs are brown and discolored and their feet are cold and slightly blue in color when in the dependent position. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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