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 D
Explanation
Choice A rationale
Administering the medication with each meal is incorrect. Clopidogrel can be taken with or without food, and there is no specific requirement to administer it with each meal. The primary concern with clopidogrel is monitoring for signs of bleeding.
Choice B rationale
Initiating contact precautions is incorrect. Clopidogrel is an antiplatelet medication and does not require contact precautions. Contact precautions are typically used for infections that can be transmitted through direct or indirect contact.
Choice C rationale
Having suction equipment at the bedside is incorrect. Suction equipment is not necessary for clients taking clopidogrel. The primary concern with clopidogrel is monitoring for signs of bleeding, not respiratory issues.
Choice D rationale
Monitoring the client for black, tarry stools is correct. Clopidogrel increases the risk of bleeding, and black, tarry stools can be an indication of gastrointestinal bleeding. It is important to monitor for this adverse effect to ensure the client’s safety.
Correct Answer is B
Explanation
ChoiceA rationale
Placing a sandbag to the lateral calf is not an effective method to prevent hip dislocation.Sandbagsaretypicallyusedtoprovidesupportandimmobilizationinothercontexts,suchasstabilizing fractures. They do not provide the necessary support to prevent hip dislocationafteratotalhiparthroplasty.
ChoiceB rationale
Placingawedgepillowbetweenthelegsisaneffectivemethodto preventhipdislocationaftera total hip arthroplasty. The wedge pillow helps to maintain proper alignment of the hip jointby keeping the legs abducted (apart) and preventing adduction (bringing the legs together),whichcancausedislocation.
ChoiceCrationale
Placing a trochanter roll against the thigh is not specifically aimed at preventing hipdislocation. Trochanter rolls are used to prevent external rotation of the hip in patients whoareimmobile,buttheydonotprovidethenecessarysupporttopreventdislocationafterhipsurgery.
ChoiceD rationale
Placing a footboard on the bed is not an effective method to prevent hip dislocation.Footboardsareusedtoprovidesupporttothefeetandpreventfootdropinbedriddenpatients,buttheydo notaddresstheriskofhipdislocation.