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 A
Explanation
A. Dyspnea on exertion: Anemia from blood loss reduces oxygen-carrying capacity, leading to symptoms like fatigue and dyspnea on exertion. The patient's low SpO₂, tachycardia, and increased respiratory rate are consistent with this finding.
B. Respiratory depression: Respiratory depression is typically associated with narcotics or other depressants, not anemia due to blood loss. The increased respiratory rate suggests a compensatory mechanism for decreased oxygenation, not depression.
C. Intense abdominal pain: While abdominal pain could be present in some conditions, it is not a direct symptom of anemia due to surgical blood loss and decreased perfusion.
D. Bradycardia: Anemia usually causes tachycardia (increased heart rate) as the body compensates for the decreased oxygenation, not bradycardia (slow heart rate). Therefore, bradycardia is unlikely in this case.
Correct Answer is A
Explanation
A. Check the client's distal pulses in both legs. It is important to assess distal pulses to ensure adequate circulation and to detect any signs of potential complications, such as arterial occlusion or hematoma formation, after cardiac catheterization.
B. Keep the client overnight. Most clients do not need to be kept overnight after cardiac catheterization unless there are complications. This option is unnecessary in routine cases.
C. Restrict the client's oral fluids. Clients are encouraged to increase oral fluids after the procedure to help flush out the contrast dye used during the catheterization and reduce the risk of kidney damage.
D. Keep the client on bed rest for 12 hr. Bed rest is required for a few hours (typically 4-6 hours) after cardiac catheterization to reduce the risk of bleeding from the puncture site. However, 12 hours of bed rest is generally not necessary unless there are specific complications.
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