The nurse is caring for a client with chronic atrial fibrillation who develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. Which of the following actions should the nurse implement first?
A)Elevate the left leg on a pillow.
B)Apply an elastic wrap to the leg.
C)Assist the client in gently exercising the leg.
D)Notify the health care provider.

Question

Quizplus · Accepted Answer

The client's history and clinical manifestations are consistent with acute arterial occlusion. Clinical manifestations of acute arterial ischemia include the "six Ps": pain, pallor, paralysis, pulselessness, paresthesia, and poikilothermia (adaptation of the limb to the environmental temperature, most often cool). Without immediate intervention, ischemia may progress quickly to tissue necrosis and gangrene within a few hours. If the nurse detects these signs, the nurse should immediately notify the health care provider. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the leg.

The Nurse Is Caring for a Client with Chronic Atrial