While assessing a client, the nurse notes that the client's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best follow up this assessment finding?
Assess the client's use of over-the-counter dietary supplements.
Implement interventions relevant to arterial narrowing
Encourage the client to increase intake of foods high in vitamin K
Adjust the client's activity level to accommodate decreased coronary output.
The Correct Answer is B
The nurse should best follow up the assessment finding of an ankle-brachial index (ABI) of 0.40 in the right leg by implementing interventions relevant to arterial narrowing.
An ankle-brachial index is a non-invasive test used to assess peripheral arterial disease (PAD). An ABI value below 0.90 indicates significant arterial narrowing and impaired blood flow to the lower extremities. An ABI of 0.40 suggests severe arterial narrowing, which puts the client at risk for reduced perfusion and potential complications such as tissue ischemia, ulceration, and gangrene.
Implementing interventions relevant to arterial narrowing is crucial in this case. These interventions may include:
- Collaborating with the healthcare provider to develop a treatment plan: This may involve prescribing medications to improve blood flow, such as antiplatelet agents or vasodilators.
- Encouraging lifestyle modifications: This can include smoking cessation, regular exercise, and maintaining a healthy diet low in saturated fats and high in fruits and vegetables.
- Promoting optimal cardiovascular health: This can involve managing other risk factors for arterial narrowing, such as hypertension, diabetes, and high cholesterol levels.
- Educating the client about the signs and symptoms of PAD: This includes teaching them to monitor for changes in skin color, temperature, and sensation in the affected limb, as well as the importance of seeking prompt medical attention if these changes occur.
Let's review the other options:
Assessing the client's use of over-the-counter dietary supplements: While it is important to assess for potential interactions between medications and dietary supplements, this would not be the immediate follow-up action for a severely reduced ABI.
Encouraging the client to increase intake of foods high in vitamin K: While maintaining a balanced diet is important for overall health, increasing vitamin K intake is not specifically indicated for addressing arterial narrowing or improving the ABI.
Adjusting the client's activity level to accommodate decreased coronary output:
Coronary output refers to blood flow to the heart muscle. Arterial narrowing in the leg does not directly affect coronary output. However, it is important to encourage appropriate physical activity for the client based on their overall cardiovascular health and exercise tolerance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Helping to position a client for a portable x-ray generally involves physically assisting the client in moving into the appropriate position or adjusting their body as needed. This task can be safely delegated to the UAP as long as they have received proper training on how to safely assist with positioning and have a clear understanding of the specific instructions provided by the radiology department.
Assisting the client to take the beta-blocker involves administering medication, which falls within the scope of nursing practice and requires the nurse's expertise in medication administration and monitoring the client's response.
Transporting the client to the intensive care unit via a stretcher involves moving the client to another unit and may require additional monitoring and coordination of care during the transfer. This task is best performed by the nurse, who can assess the client's stability, ensure appropriate documentation, and communicate effectively with the receiving unit.
Providing discharge-teaching instructions to the client going home requires the nurse to provide information about medications, wound care, follow-up appointments, and other important instructions. This task involves comprehensive education and assessment ofthe client's understanding, and is best performed by the nurse to ensure accurate and complete information is provided.
Correct Answer is ["B","C","D","E"]
Explanation
Pain level of 10 out of 10: Severe pain can stimulate the sympathetic nervous system and result in an increased heart rate.
Temperature 101.9°F: Fever can lead to an elevated heart rate as the body's response to infection or inflammation.
Hemoglobin: 7 g/dL: Low hemoglobin levels, known as anemia, can cause the heart to pump faster in an attempt to compensate for the decreased oxygen-carrying capacity of the blood.
Cocaine abuse: Cocaine is a stimulant drug that can significantly increase heart rate and cause tachycardia.
The following clinical finding would not typically be associated with tachycardia:
Blood glucose 90 mg/dL: While low or high blood glucose levels can cause symptoms, they are not directly associated with tachycardia unless they lead to significant physiological stress or hormonal imbalances.
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