A nurse is collecting data from a client who has peripheral arterial disease (PAD). Which of the following findings should the nurse expect?
Warm extremities.
Darkened skin color near extremities.
Intermittent claudication.
Edema.
The Correct Answer is C
Choice A rationale
Warm extremities are not typically associated with peripheral arterial disease (PAD). PAD usually results in reduced blood flow, leading to cooler extremities.
Choice B rationale
Darkened skin color near extremities is more commonly associated with venous insufficiency rather than PAD. PAD typically causes pale or bluish skin due to reduced blood flow.
Choice C rationale
Intermittent claudication, which is pain or cramping in the legs during exercise that subsides with rest, is a hallmark symptom of PAD. It occurs due to reduced blood flow to the muscles during activity.
Choice D rationale
Edema is more commonly associated with venous insufficiency or heart failure rather than PAD. PAD typically causes reduced blood flow, not fluid accumulation.
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Correct Answer is B
Explanation
Choice A rationale
Notifying the charge nurse is important, but the priority action is to assess the client for any adverse effects of the medication error. This ensures the client’s immediate safety.
Choice B rationale
Checking the client’s vital signs is the priority action because it allows the nurse to assess for any immediate adverse effects of the medication error, such as changes in blood pressure or heart rate.
Choice C rationale
Filling out an occurrence report is necessary for documentation and institutional policy, but it is not the immediate priority. The client’s safety and assessment come first.
Choice D rationale
Documenting an objective description of the event in the client’s chart is important for medical records, but it should be done after assessing the client’s condition.
Correct Answer is D
Explanation
Choice A rationale
Maintaining a low carbohydrate diet is not specifically recommended for clients with chronic kidney disease (CKD). Instead, the focus is on managing protein, sodium, potassium, and phosphorus intake to prevent further kidney damage and manage symptoms.
Choice B rationale
Eliminating ingestion of foods high in protein is incorrect. While protein intake should be moderated, it should not be completely eliminated. Clients with CKD are advised to consume a controlled amount of high-quality protein to reduce the burden on the kidneys while ensuring adequate nutrition.
Choice C rationale
Increasing intake of sodium-containing food is incorrect. Clients with CKD should restrict sodium intake to help control blood pressure and prevent fluid retention, which can exacerbate kidney damage.
Choice D rationale
Reducing intake of foods high in potassium is correct. Clients with CKD often have difficulty excreting potassium, leading to hyperkalemia, which can be dangerous. Therefore, it is important to limit foods high in potassium.