A patient with endocarditis develops sudden leg pain with pallor, ...

[scienceeasy]

A patient with endocarditis develops sudden leg pain with pallor, tingling, and loss of peripheral pulses. What should the nurse do first?
 
  1. notify the physician about these findings
  2. elevate the leg above the level of the heart
  3. wrap the extremity in a loose, warm blanket and apply a foot cradle
  4. perform passive range of motion (PROM) exercises to stimulate circulation

Question 2

The nurse is caring for patients on a cardiac unit. Which patient should the nurse assess first?
 
  1. patient with hypertrophic cardiomyopathy who is reporting dyspnea
  2. patient who had a cardiac catheterization and will be ambulating for the first time
  3. patient receiving antibiotics for bacterial endocarditis who is reporting anxiety and chest pain
  4. patient recovering from coronary artery bypass grafting (CABG) surgery with a temperature of 101F.

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Answer to Question 1

Correct Answer: 3
The patient is exhibiting symptoms of acute arterial occlusion due to possible embolization of a vegetative lesion. Without immediate intervention, tissue ischemia and necrosis will develop, with ultimate loss of the extremity. The nurse should first wrap the leg in a loose, warm blanket to maintain the temperature and protect the leg from injury, apply a foot cradle, then notify the physician. Elevating the leg above the heart could worsen the ischemia. Passive range of motion exercises will increase tissue demand for oxygen and increase ischemia.

Answer to Question 2

Correct Answer: 3
The patient with bacterial endocarditis is at risk for thrombus formation. This patient requires immediate attention as chest pain and anxiety are signs of pulmonary embolism (PE), which is life-threatening. Dyspnea is a chronic symptom with hypertrophic cardiomyopathy, which requires assessment; a temperature of 101F requires further assessment; and the patient ambulating for the first time will be assessed by a nurse. However, the patient with a possible PE is the most emergent.