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
Explanation
Choice A rationale
Abduction is the correct position for the client’s right leg following a right total hip arthroplasty. This position helps prevent dislocation of the hip joint by keeping the leg away from the midline.
Choice B rationale
Internal rotation should be avoided as it can increase the risk of hip dislocation. This position places stress on the new hip joint.
Choice C rationale
External rotation is also not recommended as it can lead to dislocation of the hip joint. Proper alignment is crucial for healing.
Choice D rationale
Adduction, or moving the leg towards the midline, should be avoided as it significantly increases the risk of hip dislocation. Keeping the leg in abduction helps maintain joint stability.
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. .