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The nurse is assessing a 48-year-old client with a history of
smoking during a routine clinic visit. The client, who exercises
regularly, reports having pain in the calf
during exercise that disappears at rest. Which of the following findings
requires further evaluation?
1. Heart rate 57 bpm.
2. SpO2 of 94% on room air.
3. Blood pressure 134/82.
4. Ankle-brachial index
of 0.65. 4
An Ankle-Brachial Index of 0.65 suggests moderate arterial
vascular disease in a client who is experiencing intermittent
claudication. A Doppler ultrasound is
indicated for further evaluation. The bradycardic heart rate is
acceptable in an athletic client with a normal blood pressure. The
SpO2 is acceptable; the client has a smoking history
.
An overweight client taking warfarin (Coumadin) has dry skin due to
decreased
arterial blood flow. What should the nurse instruct the client to do?
, Select all that apply.
1. Apply lanolin or petroleum jelly to intact skin.
2. Follow a reduced-calorie, reduced-fat diet.
3. Inspect the involved areas daily for new ulcerations.
4Instruct the client to limit activities of daily
living (ADLs).
5.Use an electric razor to shave
1,2,3,5
Maintaining skin integrity is important in preventing chronic ulcers and
infections. The client should be taught to inspect the skin on a daily
basis. The client should reduce weight to promote circulation; a diet
lower in calories and fat is appropriate. Because the client is
receiving Coumadin, the client is at risk for bleeding from cuts. To
decrease the risk of cuts, the nurse should suggest that the client use
an electric razor. The client with decreased arterial blood flow should
be encouraged to participate in ADLs. In fact, the client should be
encouraged to consult an exercise physiologist for an exercise
program that enhances the aerobic capacity of the body.
A client with peripheral vascular disease has undergone a right
femoral-popliteal bypass graft. The blood pressure has decreased
from 124/80 to 94/62. What should the nurse assess first?
1. IV fluid solution.
2. Pedal pulses.
3. Nasal cannula flow rate.
4. Capillary
refill 2
With each set of vital signs, the nurse should assess the dorsalis
,pedis and posterior tibial pulses. The nurse needs to ensure
adequate perfusion to the lower
, extremity with the drop in blood pressure. IV fluids, nasal cannula
setting, and capillary refill are important to assess; however, priority
is to determine the cause of drop in blood pressure and that
adequate perfusion through the new graft is maintained.
The nurse is caring for a client with peripheral artery disease who
has recently been prescribed clopidogrel (Plavix). The nurse
understands that more teaching is necessary when the client
states which of the following:
1. "I should not be surprised if I bruise easier or if my gums
bleed a little when brushing my teeth."
2. "It doesn't really matter if I take this medicine with or
without food, whatever works best for my stomach."
3. "I should stop taking Plavix if it makes me feel weak and dizzy."
4. "The doctor prescribed this medicine to make my platelets less
likely to stick together and help prevent clots from forming."
3
Weakness, dizziness, and headache are common adverse
effects of Plavix and the client should report these to the
physician if they are problematic; in order to decrease risk of
clot formation, Plavix must be taken regularly and should not
be
stopped or taken intermittently. The main adverse effect of Plavix
is bleeding, which often occurs as increased bruising or bleeding
when brushing teeth. Plavix is well absorbed, and while food may
help decrease potential gastrointestinal upset, Plavix may
be taken with or without food. Plavix is an antiplatelet agent used
to prevent clot formation in clients who have experienced or are at