Altered Tissue Perfusion 1 - Van Nostrand

complications of blood transfusions

- Febrile nonhemolytic reaction - Acute hemolytic reaction - Allergic reaction - Circulatory overload - Bacterial contamination - Transfusion related acute lung injury - Delayed hemolytic reaction - Disease acquisition - Complications of long-term transfusion therapy

blood transfusions

- O negative = universal blood donor - blood reactions are in proportion to the amount of blood received*** - review pt. hx. including hx. of transfusions and reactions, not concurrent health problems and obtain baseline assessment and VS - perform pt. teaching and obtain consent - equipment: IV (20-gauge or greater for PRBCs) and appropriate tubing, NS solution - procedure to identify pt. and blood product - monitoring of pt. and VS - post-procedure care - nursing management of adverse reactions

mobility and leg ulcers

- activity is usually restricted to promote healing - gradual progression of activity - activities to promote blood flow; encourage pt. to move about in bed and exercise upper extremities - diversional activities - pain meds prior to activities/txs. - no contact sports

NON-MODIFIABLE risk factors for atherosclerosis & PVD

- age - gender - genetics

medical management of leg ulcers

- anti-infective therapy is dependent upon infecting agent: oral antibiotics usually - compression therapy - debridement of wound - dressings Impaired Skin Integrity Impaired Physical Mobility Imbalanced Nutrition

venous ulcer

- as blood pools, it diffuses

cellulitis and lymphatic d/o's

- cellulitis: infection and swelling of skin tissues - lymphangitis: inflammation/infection of the lymphatic channels -lymphadenitis: inflammation/infection of the lymph nodes - lymphedema: tissue swelling r/t obstruction of lymphatic flow = primary: congenital or secondary: acquired obstruction

venous thromboembolism

- endothelial damage: venous stasis, altered coagulation - manifestations: deep veins = DVT & superficial veins = phlebitis which set up an inflammatory response which could result in a DVT at some point*

improving peripheral arterial circulation

- exercise and activities: walking, graded isometric exercises - positioning strategies - temp: effects of heat and cold - smoking cessation - stress reduction: constant state of stress = release of cortisone/adrenaline = vasoconstriction = hypertension*

assessment of pt. with peripheral arterial insufficiency

- health hx. - meds - isk factors - s+s of arterial insufficiency - claudication and pain at rest - color changes - weak or absent pulses - skin changes and skin breakdown Atered peripheral tissue perfusion Chronic pain Risk for impaired skin integrity Knowledge deficient

caring for pt. with leg ulcers

- hx. of the condition - tx. depends upon the type of ulcer - assess for infection - assess nutrition

goals for the pt. with peripheral arterial insufficiency

- increased arterial blood supply - promotion of vasodilatation: sock on the foot for warmth, smoking cessation, NO heating pads for prevention of burns since the temp can't be felt, NO knee-highs/compression doesn't help, pain = NSAIDs and repositioning - prevention of vascular compression - relief of pain - attainment or maintenance of tissue integrity - adherence to self-care program

complications of leg ulcers

- infection - gangrene

Raynaud's disease

- intermittent arterial vasoocclusion, usually of the fingertips or toes; specific type of PVD - Raynaud's phenomenon is associated with other underlying disease such as scleroderma - manifestations: sudden vasoconstriction results in color changes, numbness, tingling, and burning pain; spasms of the capillaries constricting = pain - episodes are usually brought on by a trigger such as cold or stress - occurs most frequently in young women - education: protect from cold/other triggers - avoid injury to hands/fingers; wear gloves; avoid hot to cold aka "chilling" - resolution: gently warm hand*

maintaining tissues integrity

- low fat/cholesterol/salt diet, good nutrition - protection of extremities and avoidance of trauma - regular inspection of extremities w/ referral for tx. and followup for any evidence of infection or inflammation - weight reduction as necessary

peripheral blood flow rate

- movement of fluid across the capillary wall; hydrostatic and osmotic force - hemodynamic resistance: blood viscosity, vessel diameter - regulation of peripheral vascular resistance - ΔP/R (pressure gradient over resistance)

medical management for PVD

- prevention - exercise program - meds: pentoxifylline (Trental) & cilostazol (Pletal) - use of anti platelet agents: to avoid sticking - surgical management

goals for the pt. with leg ulcers

- restoration of skin integrity - improved physical mobility - adequate nutrition - absence of complications

other interventions for leg ulcers

- skin integrity: skin care/hygiene and wound care, positioning of legs to promote circulation, avoidance of trauma - nutrition: measures to ensure adequate nutrition, adequate protein, vitamin C and A, iron, and zinc are especially important for wound healing, include cultural considerations and patient teaching in the dietary plan

MODIFIABLE risk factors for atherosclerosis & PVD

- smoking/nicotine - diet - high blood pressure - diabetes - obesity - stress - sedentary lifestyle - c-reatcive protein - hyperhomocysteinemia = homocysteine levels above 15 µmol/L

mesenteric ischemia

- usually irreversible unless it's found early - pain, sudden onset, out of proportion to what abdominal pain reveals, benign abdominal pain: can be touched and whatnot, but still hurts, mortality = 70%, becomes necrotic, septic

arterial ulcer

- usually starts as a pinpoint in a place of pressure, as ischemia becomes inflamed it grows outward in a concentric circle

prevention of DVT

1. HYRDATION 2. get up every hour and move around 3. ted stockings 4. aspirin q am (81 vs 325 mg) 81 mg for prophylactic dose, anti-inflammatory at the epithelial level of the vessels or 325 mg risk for dose, anti-platelet 5. subcutaneous heparin or LMWH, warfarin for extended therapy

atherosclerosis

1. fatty streak 2. fibrous plaque 3. complicated lesion: hemorrhage, ulceration, calcification, thrombosis *stroke, MI, gangrene - mms. below blockage begins to die if left untreated

Cancer can cause changes in what component of Virchow's triad? A. Blood coagulability B. Vessel walls C. Blood flow D. Blood viscosity

A

Mike, a 43-year old construction worker, has a history of hypertension. He smokes two packs of cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping with stress. His current concern is calf pain during minimal exercise that decreased with rest. The nurse assesses Mike's symptoms as being associated with peripheral arterial occlusive disease. The nursing diagnosis is probably: A. Alteration in tissue perfusion related to compromised circulation B. Dysfunctional use of extremities related to muscle spasms C. Impaired mobility related to stress associated with pain D. Impairment in muscle use associated with pain on exertion.

A

During an assessment of a patient's abdomen, a pulsating abdominal mass is noted by the healthcare provider. Which of the following should be the healthcare provider's next action? A. Assess femoral pulses B. Obtain a bladder scan C. Measure the abdominal circumference D. Ask the patient to perform a Valsalva maneuver

A Rationale: A pulsating mass may indicate the presence of an abdominal aneurysm. Assessing the pulses distal to the aneurysm will provide information regarding the degree of circulatory compromise. B: A bladder scan would be an appropriate action if the healthcare provider suspects a distended bladder, which may present as a non-pulsating suprapubic enlargement. C: Measuring the abdominal circumference may be an appropriate assessment for a patient who has generalized abdominal enlargement, which may be seen in liver dysfunction. Increasing abdominal girth may be associated with a ruptured aneurysm. D: Asking the patient to bear down (Valsalva maneuver) is appropriate if a hernia is suspected.

The healthcare provider is reviewing risk factors for the development of an abdominal aortic aneurysm (AAA). Which of these inherited disorders in a patient's history is most likely related to the development of an AAA? A. Marfan syndrome B. Klinefelter syndrome C. Trisomy 21 D. Sickle cell anemia

A Rationale: AAAs develop when there is degradation of the normal aortic structure, consisting of smooth muscle and the connective tissues collagen and elastin. The development of an AAA is associated with connective tissue disorders such as Marfan syndrome. Marfan syndrome results in connective tissue deficiency and ineffective collagen cross-linking, resulting in a weakened aorta which is prone to aneurysm or dissection. - Recall some of the major problems encountered by individuals with these genetic disorders. Some of these genetic disorders involve the presence of extra chromosomes, while others involve mutations of genes that code for important proteins.

A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is: A. Normal because of the increased blood flow through the leg B. Slightly deteriorating and should be monitored for another hour C. Moderately impaired, and the surgeon should be called. D. Adequate from the arterial approach, but venous complications are arising.

A Rationale: An expected outcome of surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. Options 2, 3, and 4 are incorrect interpretations.

After a surgical procedure to perform an embolectomy, the nurse should provide which of the following client teaching? A. Use a soft toothbrush B. May take ibuprofen for elevated temperature C. Apply tight fitting support hose D. Small amount of bleeding in the urine is normal

A Rationale: Ibuprofen is an NSAIDs which may enhance the action of anticoagulants. Pressure on tissue may increase the risk of bleeding or bruising when clients are ingesting anticoagulants. Blood in the urine is abnormal and should be reported to the health care provider. Anticoagulant therapy is initiated to prevent further clot formation and recurrent embolism. Anticoagulants increase the bleeding time by 1.5-2.5 of the normal level resulting increased of bleeding gums.

A nurse has an order to begin administering warfarin sodium (coumadin) to a client. While implementing this order, the nurse ensures that which of the following medications is available on the nursing unit as the antidote for Coumadin? A. Vitamin K B. Aminocaproic acid C. Potassium chloride D. Protamine sulfate

A Rationale: The antidote to warfarin (Coumadin) is Vitamin K and should be readily available for use if excessive bleeding or hemorrhage should occur.

The healthcare provider is assessing a patient with a diagnosis of an abdominal aneurysm (AAA). Which of these assessment findings will the healthcare provider anticipate? A. A bruit auscultated over the periumbilical area B. A friction rub auscultated in the right upper abdominal quadrant C. A venous hum auscultated in the epigastric area. D. Tenderness felt over the costovertebral angle (CVA)

A Rationale: Turbulent blood flow within an abdominal aortic aneurysm may create a whooshing sound called a bruit. B: A friction rub heard in the right upper quadrant as an inflamed liver rubs against the peritoneum. C: A venous hum is the result of collateral circulation between the portal and systemic venous systems, as seen in liver disease. D: CVA tenderness is an indication of kidney problems such as pyelonephritis or renal calculi.

Because a client has acute arterial occlusion in the right leg, the nurse assesses for the following most relevant signs/symptoms? (Select all that apply.) A. Numbness, tingling and pain B. No pulse felt proximal to the blockage C. Pale, cool skin D. Swelling, tenderness and erythema

A & C Rationale: Manifestations of acute arterial occlusion include pallor or mottling, cool or cold skin, and pulselessness distal to the blockage. Swelling, tenderness and erythema are associated with venous problems.

A client with a deep vein thrombosis experiences acute chest pain and dyspnea. The nurse should perform which of the following? (Select all that apply.) A. Elevate the head of the bed B. Check the pulse in the affected extremity C. Flex the client's knees and place in a supine position D. Notify the physician of the situation

A & D Rationale: Elevate the head of the bed to assist ventilation. Immediately report complaints of chest pain and shortness of breath to the physician.

Buerger's disease is characterized by all of the following except: A. Arterial thrombosis formation and occlusion B. Lipid deposits in the arteries C. Redness or cyanosis in the limb when it is dependent D. Venous inflammation and occlusion

B

With peripheral arterial insufficiency, leg pain during rest can be reduced by: A. Elevating the limb above heart level B. Lowering the limb so it is dependent C. Massaging the limb after application of cold compresses D. Placing the limb in a plane horizontal to the body

B

The most appropriate nursing diagnosis for an elderly client with peripheral vascular disease who tells the nurse, "My legs won't let me do what I want to do" includes which of the following? A. Fatigue B. Activity Intolerance C. Ineffective Health Maintenance D. Risk for Noncompliance

B Rationale: Activity Intolerance is directed toward the client's need. Fatigue is a diagnosis based on assumption not fact. Ineffective health maintenance relates to the client's willingness to take responsibility for disease management. Noncompliance is the failure to follow an identified treatment plan.

A nurse is caring for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse would inspect the surgical site most closely for signs of: A. Thrombosis and infection B. Bleeding and infection C. Bleeding and wound dehiscence. D. Wound dehiscence and evisceration.

B Rationale: After inferior vena cava insertion, the nurse inspects the surgical site for bleeding and signs and symptoms of infection. Otherwise, care is the same as for any post-op client.

The nurse evaluates the effectiveness of a regular exercise program for a client with peripheral arterial disease by asking the client about which of the following? A. Progressive decrease in peripheral pulses B. How quickly intermittent claudication occurs. C. Extent of ruber-colored lower extremities D. Degree of bilateral edematous ankles

B Rationale: Claudication limits activities. Gradual increases in duration and intensity of exercise promotes the development of collateral circulation, and improves exercise tolerance while decreasing episodes of claudication.

A standard of nursing practice associated with the care of a client with deep vein thrombosis includes which of the following? A. Encourage ambulation to maintain circulation B. Elevate the legs on a pillow, above the level of the heart to promote venous return C. Massage the calf to promote vasodilation and reabsorption of excess fluid D. Remove antiembolic stockings throughout the night to prevent venous stasis

B Rationale: Elevating extremities promotes venous return and reduces peripheral edema. Ambulation exacerbates the inflammatory process and increases edema. Massaging the calf could dislodge the clot. Antiembolic stockings should be removed for only short periods to enhance skin circulation.

A client comes to the outpatient clinic and tells the nurse that he has had legs pains that begin when he walks but cease when he stops walking. Which of the following conditions would the nurse assess for? A. An acute obstruction in the vessels of the legs B. Peripheral vascular problems in both legs C. Diabetes D. Calcium deficiency

B Rationale: Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. If an obstruction were present, the leg pain would persist when the client stops walking. Low calcium levels may cause leg cramps but would not necessarily be related to walking.

A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following assessment findings by the nurse is probably unrelated to the aneurysm? A. Pulsatile abdominal mass B. Hyperactive bowel sounds in that area C. Systolic bruit over the area of the mass D. Subjective sensation of "heart beating" in the abdomen.

B Rationale: Not all clients with abdominal aortic aneurysms exhibit symptoms. Those who do describe a feeling of the "heart beating" in the abdomen when supine or be able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm.

Before teaching a client about essential hypertension, the nurse should collect which of the following health history elements? A. Extent of involvement in high energy activities B. Amount of alcohol intake per day or week C. Estimate of daily fluid intake D. Amount of multivitamin supplements ingested

B Rationale: Reducing alcohol intake to one or two drinks per day can decrease the blood pressure. High energy activities would burn more calories. Increasing fluid intake would not decrease the blood pressure. Taking multivitamin supplements are not needed with good dietary habits and never in large doses.

In preparation for discharge of a client with arterial insufficiency and Raynaud's disease, client teaching instructions should include: A. Walking several times each day as an exercise program. B. Keeping the heat up so that the environment is warm C. Wearing TED hose during the day D. Using hydrotherapy for increasing oxygenation

B Rationale: The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will also be useful when preventing vasoconstriction, but TED hose would not be therapeutic. Walking would most likely increase pain.

While recovering from an endovascular aortic repair (EVAR) of an abdominal aortic aneurysm (AAA), the patient experiences numbness and tingling in the feet. What is the healthcare provider's priority action? A. Assist the patient to ambulate B. Palpate the pedal pulses C. Gently massage the legs and feet D. Apply warm compresses to the feet

B Rationale: The healthcare provider will monitor pulse and check for pallor, pain, paresthesia, and paralysis; assessing temperature of extremities can be remembered by the words "polar" or "poikilothermia" (varying temperature). Numbness and tingling of the feet and loss of pedal pulses may indicate an occlusion of the graft, which requires immediate attention. The healthcare provider's assessments and interventions will focus on the arterial circulation distal to the aneurysm.

A 24-year old man seeks medical attention for complaints of claudication in the arch of the foot. A nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next assess the client for: A. Familial tendency toward peripheral vascular disease B. Smoking history C. Recent exposures to allergens D. History of insect bites

B Rationale: The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests Buerger's disease. This is an uncommon disorder characterized by inflammation and thrombosis of smaller arteries and veins. This disorder typically is found in young adult males who smoke. The cause is not known precisely but is suspected to have an autoimmune component.

A client who has been receiving heparin therapy also is started on warfarin sodium (coumadin). The client asks the nurse why both medications are being administered. In formulating a response, the nurse incorporates the understanding that warfarin sodium: A. Stimulates the breakdown of specific clotting factors by the liver, and it takes 2-3 days for this is exhibit an anticoagulant effect. B. Inhibits synthesis of specific clotting factors in the liver, and it takes 3 to 4 days for this medication to exert an anticoagulation effect. C. Stimulates production of the body's own thrombolytic substances, but it takes 2-4 days for it to begin. D. Has the same mechanism action of heparin, and the crossover time is needed for the serum level of warfarin sodium to be therapeutic.

B Rationale: Warfarin sodium works in the liver and inhibits synthesis of four vitamin K-dependent clotting factors (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of warfarin is exhibited.

Varicose veins can cause changes in what component of Virchow's triad? A. Blood coagulability B. Vessel walls C. Blood flow D. Blood viscosity

C

When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows not to expect therapeutic benefits for: A. At least 12 hours B. The first 24 hours C. 2-3 days D. 1 week

C

An unconscious patient arrives at the emergency department. Periumbilical (Cullen's sign) and flank ecchymosis (Grey Turner's sign) is noted , and a ruptured abdominal aortic aneurysm (AAA) is suspected. Which of these additional assessment findings will the healthcare provider anticipate? A. Decorticate posturing B. Expiratory wheezes C. Pale, clammy skin D. Pinpoint pupils

C Rationale: A patient with a ruptured AAA will have signs and symptoms of hypovolemic shock. A: Decorticate posturing is associated with interruption of voluntary motor tracts in the cerebral cortex secondary to increased intracranial pressure and would not be an expected finding in this case. D: Pinpoint pupils are observed if there is damage to the pons or due to the influence of certain drugs.

Which of these interventions should be the highest priority when caring for a patient with suspected abdominal aortic aneurysm (AAA) rupture? A. Inserting an indwelling urinary catheter B. Obtaining a STAT electrocardiogram (EKG) C. Maintaining blood pressure D. Increasing cardiac contractility

C Rationale: Blood pressure will drop quickly as a large amount of blood volume is lost, so maintaining sufficient blood pressure is key. - All of these interventions may be done on behalf of the patient. Considering the patient's most acute problem, what would be the first priority? - If rupture of the AAA is suspected, the patient is at risk for hypovolemia.

Which of the following characteristics is typical of the pain associated with DVT? A. Dull ache B. No pain C. Sudden onset D. Tingling

C Rationale: DVT is associated with deep leg pain of sudden onset, which occurs secondary to the occlusion. A dull ache is more commonly associated with varicose veins. A tingling sensation is associated with an alteration in arterial blood flow. If the thrombus is large enough, it will cause pain.

After surgical repair of an abdominal aortic aneurysm, the client develops evidence of graft leakage. The nurse should monitor for which of the following signs/symptoms? A. Significant increase in blood pressure and pulse B. Pitting edema of the lower extremities C. Enlarged ecchymotic areas around the perineal region D. Urinary retention

C Rationale: Eccymoses of the scrotum, perineum, or penis or an expanding hematoma are manifestations of a graft leak.

The healthcare provider is evaluating effectiveness of discharge teaching for a male patient following an abdominal aortic aneurysm (AAA) repair. Which of these statements made by the patient indicates the teaching has been successful? A. "I'll be able to resume my usual work-out at the gym." B. "I will take my radial pulse each day and keep track of the rate." C. "It's possible that I may experience some sexual dysfunction." D. "I should avoid being around people who are sick."

C Rationale: Male patients often experience erectile dysfunction after AAA repair due to decreased blood flow to the pelvic area during surgery. B: Patients are taught to palpate pulses below the level of the repair. The strength and quality of the pulse is more important than the rate. D: Patients will be taught to recognize signs and symptoms of post-surgical infection, but avoiding communicable infections, although advisable, is not the priority.

During the assessment of a client admitted for the repair of an abdominal aneurysm, the nurse should perform which of the following precautions? A. Auscultate the abdomen for sounds peculiar to an aneurysm B. Auscultate the abdomen for increased bowel motility C. Avoid palpation of the abdominal wall D. Locate the mass via palpation of the abdomen and place an X over the area

C Rationale: Palpating the mass may result in risk of rupture.

The healthcare provider is assessing a patient who has a been diagnosed with an abdominal aortic aneurysm (AAA). Which assessment finding is an indication that the aneurysm is expanding? A. Hoarseness and cough B. Dysphasia C. A report of lower back pain D. Anginal pain

C Rationale: Symptoms of an AAA are the result of compression of abdominal structures, so back and abdominal pain are often reported. As aneurysms enlarge they can compress nearby structures and nerves, causing a variety of signs and symptoms. A & B: Compression of the esophagus from a thoracic aortic aneurysm can cause dysphasia, cough, and hoarseness if the laryngeal nerve is compressed. D: Anginal pain may be a symptom of compromised cardiac perfusion secondary to a thoracic aortic aneurysm.

Because a client with a left mastectomy experienced secondary lymphedema, the nurse includes which of the following in the care plan? A. Limit the number of intramuscular (IM) injections B. Use 20-30 weights for 10 repetitions daily C. Apply compression stocking during the day D. Decrease dietary sodium intake

C Rationale: Using weights is likely to increase blood flow. Since drainage is impeded, it is likely to increase edema. Secondary lymphedema is an acquired condition, resulting from damage, obstruction, or removal of lymphatic vessels. Compression stocking increases drainage during most active hours.

A significant cause of venous thrombosis is: A. Altered blood coagulation B. Stasis of blood C. Vessel wall injury D. All of the above

D

The most important factor in regulating the caliber of blood vessels, which determines resistance to flow, is: A. Hormonal secretion B. Independent arterial wall activity C. The influence of circulating chemicals D, The sympathetic nervous system

D

The most important factor in regulating the caliber of blood vessels, which determines resistance to flow, is: A. Hormonal secretion B. Independent arterial wall activity. C. The influence of circulating chemicals D. The sympathetic nervous system

D

While assessing the peripheral circulation of a patient with a diagnosis of an abdominal aortic aneurysm (AAA), the healthcare provider notes patchy mottling of the feet and toes. Pedal pulses are present. How should the healthcare provider interpret these findings? A. The patient's peripheral artery disease has progressed B. The patient has a history of Raynaud Phenomenon C. This is evidence of digital clubbing secondary to pulmonary disease D. The patient's digital arteries have become occluded

D Rationale: AAAs may spontaneously embolize plaque, causing an acute occlusion of some of the digital arteries, a problem referred to as "Blue Toe Syndrome." Because small arteries are affected, pedal pulses are often present. A: Patients who have an AAA may also have peripheral artery disease, but in this case pedal pulses would not be palpable. B: Raynaud Phenomenon is characterized by intermittent vasoconstriction of the digital arteries. Color changes may be evident, but the disorder is not associated with AAA.

After obtaining a blood pressure of 162/74 on the right arm of a first-time-visit, elderly client, the nurse should perform which of the following activities? A. Determine if client is ingesting antihypertensive correctly B. Determine if client is nervous about being new to the clinic C. Determine if client has funds to purchase antihypertensive medications D. Measure blood pressure on the left arm

D Rationale: Measuring the B/P on both arms is commonly associated with establishing a diagnosis of hypertension. The elderly client with a blood pressure of 162 / 74 has systolic hypertension with an elevated pulse pressure.

The client with Raynauds's disease asks the nurse, "Why do my fingers turn blue then white and hurt?" Which of the following is the best response? A. "This is related to inflammation of small veins in the hand." B. "This is related to decreased upper arm circulation." C. "This is related to swelling and edema in the fingers and hand." D. "This is related to spasms of the small arteries in the fingers."

D Rationale: Raynaud's disease is characterized by episodes of intense vasospasm in the small arteries and arterioles of the fingers and sometimes the toes.

IV heparin therapy is ordered for a client. While implementing this order, a nurse ensures that which of the following medications is available on the nursing unit? A. Vitamin K B. Aminocaproic acid C. Potassium chloride D. Protamine sulfate

D Rationale: The antidote to heparin is protamine sulfate and should be readily available for use if excessive bleeding or hemorrhage should occur

A client is admitted with a venous stasis leg ulcer. A nurse assesses the ulcer, expecting to note that the ulcer: A. Has a pale colored base B. Is deep, with even edges C. Has little granulation tissue D. Has brown pigmentation around it.

D Rationale: Venous leg ulcers, also called stasis ulcers, tend to be more superficial than arterial ulcers, and the ulcer bed is pink. The edges of the ulcer are uneven, and granulation tissue is evident. The skin has a brown pigmentation from accumulation of metabolic waste products resulting from venous stasis. The client also exhibits peripheral edema. (options 1, 2, and 3 is due to tissue malnutrition; and thus us an arterial problem)

What teaching components should the nurse include in a care plan for a client with chronic venous insufficiency A. Sitting in an upright not slouched position as much as possible B. Developing lifestyle changes C. Applying cool compresses to the affected areas twice daily D. Walking as much as feasible

D Rationale: Walk as much as possible but avoid sitting or standing for long periods of time. Developing life style changes, if any, would have been discussed well before discharge. Cool compresses caused vasoconstriction and would not be used with this venous problem.

choose the statements that correctly matches the HTN med with its side effect. select all that apply. a. direct vasodilators may cause headaches and tachycardia b. with thiazide diuretics, monitor serum K+ levels c. with adrenergic inhibitors, cough is a common side effect d. with ACE inhibitors, assess for bradycardia e. beta-blockers may cause sedations

a & b rationale: thiazide diuretics may deplete K+, many clients will need a supplement c: adrenergic inhibitors can cause sedation and fatigue d: ACE inhibitors may cause a mild to severe dry cough e: beta-blockers may induce decreased HR; pulse rate should be assessed before administration

which of the following statements are true when the RN is measuring BP? select all that apply. a. the pt.'s arm should be positioned at the level of the heart b. using a BP cuff that is too small will give a higher BP measurement c. using a BP cuff that is too large will give a higher BP measurement d. ask the pt. to sit quietly while the BP is being measured e. the pt.'s BP should be taken 1 hr after the consumption of etoh

a, b & d rationale: all true c: bigger cuff will give a low BP compared to the actual BP e: pt. should avoid drinking etoh or smoking cigs or drinking caffeine 30 min before BP is measured

when measuring the BP in each of the pt.'s arms, the RN recognize that in the healthy adult, which of the following is true? a. pressures should not differ more than 5 mmHg between arms b. pressures must be equal in both arms c. pressures may vary, with the higher pressure found in the left arm d. pressures may vary 10 mmHg or more between arms

a. rationale: normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mmHg between arm pressure b. the pressures in each arm don't have to be equal in order to be considered normal c. not anticipated to be higher than the right as a normal anatomic variant d. indicate an abnormal finding

a 55-year-old man newly dx.'d with HTN returns to his MD's office for a routine follow-up appt. after several months of tx. with Lopressor (metoprolol). during the RN's initial assessment the pt.s' BP is 180/90 mmHg. the pt. states that he doesn't take his med as prescribed. which of the following is the best response by the RN? a. "the med you were prescribed may cause sexual dysfunction; are you experiencing this side effect?" b. "be certain to discuss your noncompliance with your med regimen with the MD." c. "your HTN must be treated with meds; you need to take your Lopressor every day." d. "it's very important for you to take your med as prescribed, or your could experience a stroke."

a. rationale: the RN needs to understand why the pt. isn't taking his med. Lopressor is a beta-blocker and all pts. should be informed that beta-blockers might cause sexual dysfunction and that otters meds are available if that occurs.

hypertension the can be attributed to an underlying cause is termed which of the following? a. secondary b. primary c. isolated systolic d. essential

a. secondary rationale: may be caused by a tumor of the adrenal gland b. has no underlying cause c. demonstrated by readings in which the systolic pressure exceeds 140 mmHg and the diastolic measurement is normal/near normal (less than 90 mmHg) d. has no underlying cause

officially, HTN is dx.'d when the pt. demonstrates a systolic BP greater than ____ mmHg and a diastolic BP greater than _____ mmHg over a sustained period. a. 120, 70 b. 140, 90 c. 130, 80 d. 110, 60

b. rationale: according to the categories of BP levels established by JNC, stage 1 HTN is demonstrated by a systolic pressure of 140 - 159, or a diastolic pressure of 90 - 99 a, c & d: WNL

which of the following findings indicate that HTN is progressing to target organ damage? a. urine output of 60 mL over 2 hrs b. chest XR showing pneumonia c. retinal blood vessel damage d. BUN level of 12 mg/dL

c rationale: eye exams are important because retinal blood vessel damage indicates similar damage elsewhere in the vascular system - question about blurred vision, spots in front of the eyes, and diminished visual acuity. the hearts, nervous system, and kidneys are also carefully assessed. a & d: WNL b: not indicative of target organ damage

target organ damage from untreated/under-treated HTN includes which of the following? select all that apply. a. hyperlipidemia b. diabetes c. heart failure d. retinal damage e. stroke

c, d & e rationale: target organ systems include cardiac, cerebrovascular, peripheral vascular, renal, and the eye. a & b: risk factors for the development of HTN

a pt. is admitted to the ICU with a dx. of HTN crisis. the pt.'s BP is 200/130 mmHg. the RN is preparing to administer IV Nitropress (nitroprusside). upon assessment, which of the following pt. findings requires immediate intervention by the RN? a. chest pain score 3/10 b. nausea and severe headache c. left arm numbness and weakness d. urine output of 40 mL over the last hour

c. rationale: HTN emergencies are acute, life-threatening BP elevations that require prompt tx. in an ICU setting b/c of the serious target organ damage that may occur. the finding of left arm numbness and weakness may indicate the pt. is experiencing neuro symptoms associated with an ischemic stroke b/c of the severely elevated BP and requires immediate interventions. a & b: require intervention, but not urgent in comparison to the neuro changes d: WNL

the RN teaches the pt. which of the following guidelines regarding lifestyle modifications for HTN? a. stop etoh intake b. reduce smoking to no more than 4 cigs a day c. maintain adequate dietary intake of fruits and veggies d. limit aerobic physical activity to 15 min, 3x/week

c. rationale: consuming a diet rich in fruits, veggies, low-fat dairy products with a reduced content of saturated and total fat, dietary Na+ education, and physical activity all help to reduce HTN a: moderate etoh use b: tobacco should be avoided d: at least 30 min daily

a 66-year-old client present to the ER c/o a severe headache and mild nausea for the last 6 hrs. upon assessment, the pt.'s BP is 210/120 mmHg. the pt. has a hx. of HTN for which he takes 1.0 mg of clonidine (Catapres) 2x/day for. which of the following questions is the most important for the RN to ask the pt. next? a. "Did you take any medication for you headache?" b. "Do you have a dry mouth or nasal congestion?" c. "Hav you taken your prescribed Catapres today?" d. "Are you having chest pain or SOB?"

c. rationale: pts. need to be informed that rebound HTN can occur if anti-HTN meds are suddenly stopped.

the RN is caring for a client who is prescribed a diuretic medication for the tx. of HTN. the RN recognizes that which of the following med conserves K+? a. Diuril (chlorothiazide) b. Hygroton (chlorothaliadone) c. Aldactone (spironolactone) d. Lasix (furosemide)

c. rationale: this med is K+ sparing diuretic a & b: cause mild hypokalemia d: causes loss of K+ from the body

a 35-year-old female pt. has been dx.'d with HTN. the pt. is a stock-broker, smokes daily, and is also a diabetic. during a follow-up appt., the pt. states that she finds it cumbersome and time consuming to visit the doctor regularly just to check her BP. as the RN, which of the following aspects of pt. teaching would you recommend? a. advising smoking cessation b. administering glycemic control c. discussing methods for stress reduction d. purchasing a self-monitoring BP cuff

d. rationale: b/c the pt. finds it time consuming to visit the MD just for a BP reading, as the RN, you can suffuse the use of an automatic cuff at a local pharmacy, or purchasing a self-monitoring cuff. a, b & c: would consist pt. education in managing HTN

the RN understands that pt. education r/t antihypertensive meds should include all of the following instructions except for which of the following? a. avoid OTC cold, weight reduction, and sinus meds b. avoid hot baths, exercise, and etoh within 3 hours of taking vasodilators c. don't stop taking meds abruptly d. if a dosage is missed, double up on the next one to catch up

d. rationale: doubling doses could cause serious hypotension and is not recommended. a: many OTC preparations can precipitate hypotension b: these are all vasodilators and should be avoided c: stopping antihypertensives abruptly can precipitate a severe hypertensive reaction and is not recommended

it is important for the RN to encourage the pt. dx.'d with hypertension to rise slowly from a sitting or lying position for which of the following reasons? a. gradual changes in position help reduce the BP to resupply O2 to the brain b. gradual changes in position provide time for the heart to reduce its rate of contraction to resupply O2 to the brain c. gradual changes in position help reduce the heart's work to resupply O2 to the brain d. gradual changes in position provide time for the heart to increase rate of contraction to resupply O2 to the brain

d. rationale: gradual change provides time to increase rate of contraction not BP or HR

the RN understands that an overall goal of HTN management includes which of the following? a. no c/o of postural hypotension b. pt. maintains a normal BP reading c. no c/o sexual dysfunction d. no indication of target organ damage

d. rationale: prolonged BP elevation gradually damages blood vessels throughout the body, particularly in target organs such as the heart, kidneys, brain, and eyes. the overall goal of management is that the pt. doesn't experience target organ damage. a & c: side effects of certain meds b: desired effects of anti-HTN meds

the Rn is caring for a client newly dx.'d with secondary HTN. which of the following conditions contributes to the development of secondary HTN? a. acid-based imbalance b. hepatic function c. calcium deficit d. renal disease

d. rationale: secondary HTN occurs when a cause for the high BP can be identified. these causes include renal parenchymal disease, narrowing of the renal arteries, hyperaldosteronism, pheochromocytoma, certain meds such as prednisone, Epogen, and coarctation of the aorta, and can also occur with pregnancy

the RN is caring for a client who has had hydrochlorothiazide added to her med regimen for the treatment of HTN. which of the following instructions should the RN give the pt? a. "you may drink etoh while taking this med." b. "take this med before going to bed." c. "you may develop dry mouth or nasal congestion while on this med." d. "increase the amount of fruits and veggies you eat."

d. rationale: thiazide diuretics cause loss of Na+, K+, and Mg+; the pt. should be encouraged to eat fruits and veggies which are high in K+. a: postural hypotension may be potentiated by etoh b: diuretics may cause increased urination c: nope