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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. CT scan without contrast dye: A CT scan without contrast dye is a non-invasive diagnostic procedure that does not require written informed consent in most cases.
B. Echocardiogram: An echocardiogram is a non-invasive ultrasound of the heart and typically does not require written informed consent.
C. Electrocardiogram: An electrocardiogram (ECG) is a simple, non-invasive test to monitor heart activity and does not require written informed consent.
D. Nuclear stress test: A nuclear stress test involves injecting a radioactive substance and placing stress on the heart. Due to its invasive nature and potential risks, written informed consent is required for this procedure.
Correct Answer is D
Explanation
A. "You should expect to feel some tingling in the affected limb the day following the procedure." Tingling in the limb could indicate nerve or circulatory problems and should be reported immediately. It is not a normal post-procedure expectation.
B. "You might be asked to perform mild exercises during the procedure." Clients are typically instructed to remain still during a cardiac catheterization to avoid complications at the insertion site. Mild exercises are not a part of the procedure.
C. "You should not eat or drink for 4 hr following the procedure." NPO (nothing by mouth) status is usually required before the procedure, not after. Clients are encouraged to drink fluids after the procedure to help flush the contrast dye from their system.
D. "You might have to lie in bed for 6 hr after the procedure." After a cardiac catheterization, especially with a femoral artery approach, clients may be required to remain on bed rest for 4-6 hours to prevent bleeding or complications at the catheter insertion site.
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