A nurse is caring for a client with peripheral artery disease who has an arterial ulcer. Which of the following best describes the mechanism for developing the clinical problem?
Swelling of the lower extremity can create a wound that is difficult to heal.
Decreased blood flow to the area can cause the wound and decrease the healing.
Lower extremity compression stockings likely caused the wound to occur.
Increased blood sugar associated with the condition is likely the cause of the wound not healing.
The Correct Answer is B
A. Swelling of the lower extremity can create a wound that is difficult to heal. Swelling typically relates to venous ulcers, not arterial ulcers, which are caused by reduced blood flow.
B. Decreased blood flow to the area can cause the wound and decrease the healing. Peripheral artery disease causes decreased blood flow, leading to poor oxygenation and slow healing of arterial ulcers.
C. Lower extremity compression stockings likely caused the wound to occur. Compression stockings are used in venous insufficiency and do not cause arterial ulcers.
D. Increased blood sugar associated with the condition is likely the cause of the wound not healing. While high blood sugar can impair healing, decreased blood flow is the primary cause of arterial ulcers in PAD.
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Correct Answer is B
Explanation
A. Slow: Atrial fibrillation typically leads to an irregular, often rapid pulse, not necessarily slow.
B. Irregular: Atrial fibrillation causes an irregular pulse due to uncoordinated atrial contractions.
C. Bounding: A bounding pulse is associated with conditions like high cardiac output or fluid overload, not atrial fibrillation.
D. Not palpable: The pulse in atrial fibrillation is usually palpable but irregular.
Correct Answer is B
Explanation
A. Obtain a blood sample. Although obtaining a blood sample is essential for cardiac enzyme levels, it is not the highest priority. Addressing oxygenation takes precedence to relieve hypoxia.
B. Initiate oxygen therapy. Oxygen is the first priority to improve oxygenation in a client showing signs of hypoxia (cyanosis, dyspnea), which can prevent further ischemic damage to the heart.
C. Attach the leads for a 12-lead ECG. While obtaining an ECG is essential for diagnosing myocardial ischemia, ensuring oxygenation is more critical in this moment.
D. Insert the IV catheter. An IV line is necessary to administer fluids and medications, but oxygenation should be prioritized first to stabilize the client.