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 A

Explanation

A. 42 units: The nurse needs to prepare 14 units of regular insulin and 28 units of NPH insulin, for a total of 42 units. Both insulins can be combined in the same syringe.

B. 32 units: This option underestimates the total units. The correct total is 42 units, not 32.

C. 14 units: This only accounts for the regular insulin dose. The client also requires 28 units of NPH insulin.

D. 28 units: This only accounts for the NPH insulin dose. The client also requires 14 units of regular insulin.

A. Check pedal pulses every 15 min. B. Keep the client in high-Fowler's position for 6 hr. C. Remind the client not to turn from side to side. D. Perform passive range-of-motion for the affected extremity.

Correct Answer is A

Explanation

A. Check pedal pulses every 15 min. Checking pedal pulses every 15 minutes is essential to monitor for adequate blood flow to the extremity and to detect any signs of arterial obstruction or complications at the catheter insertion site.

B. Keep the client in high-Fowler's position for 6 hr. The client should remain flat or in a low-Fowler's position to reduce the risk of bleeding at the femoral artery access site. High-Fowler's position is contraindicated.

C. Remind the client not to turn from side to side. Clients may be allowed to turn gently, but they should avoid putting pressure on the insertion site. Complete immobility is unnecessary.

D. Perform passive range-of-motion for the affected extremity. Passive range of motion is not appropriate in the immediate post-procedure period, as the extremity should remain still to prevent bleeding.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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