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 ["A","B","C","D"]
Explanation
Choice A rationale
Obtaining the client’s weight is essential before hemodialysis to assess fluid status and determine the amount of fluid to be removed during the procedure. Accurate weight measurement helps in preventing complications such as hypotension or fluid overload.
Choice B rationale
Verifying the glomerular filtration rate (GFR) is important in assessing the kidney function of the client. GFR helps in determining the stage of chronic kidney disease and the appropriate dialysis regimen. It also aids in monitoring the effectiveness of the treatment.
Choice C rationale
Checking the graft site for a palpable thrill is crucial in assessing the patency of the vascular access used for hemodialysis. A palpable thrill indicates that the graft is functioning properly and allows for adequate blood flow during dialysis. Absence of a thrill may indicate a blockage or malfunction of the graft.
Choice D rationale
Documenting vital signs is a standard nursing practice before, during, and after hemodialysis. Monitoring vital signs helps in detecting any changes in the client’s condition, such as hypotension, hypertension, or arrhythmias, which may occur during the procedure. It ensures timely intervention and promotes client safety.
Choice E rationale
Administering a sedative to the client is not a standard practice for hemodialysis. Sedatives are generally not required for the procedure and may pose risks such as respiratory depression or altered mental status. The focus should be on providing comfort and reassurance to the client without the use of sedatives.
Correct Answer is A
Explanation
Choice A rationale
Serving cooked fruit with meals is an appropriate intervention for a client with a low WBC count after chemotherapy. Cooking fruit helps eliminate potential pathogens, reducing the risk of infection.
Choice B rationale
Reporting temperatures greater than 39.5°C (102.3°F) lasting more than 4 hours is not appropriate. A lower threshold for fever should be used, as even a slight increase in temperature can indicate infection in immunocompromised clients.
Choice C rationale
Placing the client in a room with negative-pressure airflow is not necessary for clients with low WBC counts. This intervention is typically used for clients with airborne infections.
Choice D rationale
Instructing the client to use an incentive spirometer every 4 hours is beneficial for lung health but does not directly address the risk of infection associated with low WBC counts. .