Ch 37 Vascular Disorders, Chapter 37: Vascular Disorders, Chapter 37 Vascular Disorders, Chapter 37 Vascular Disorders, Chapter 37: Vascular Disorders, Chapter 37: Vascular Disorders, STROKE--CHAPTER 57, Lewis 57: Stroke, Ch. 57 Stroke, Chapter 57: S...

Which instruction is a key aspect of teaching for the patient on anticoagulant therapy? a. Monitor for and report any signs of bleeding b. Do not take acetaminophen (Tylenol) for a headache c. Decrease your dietary intake of foods containing vitamin K d. Arrange to have your blood drawn twice a week to check drug affects

A Teach patients taking anticoagulants to monitor and report any signs of bleeding, which can be a serious complication. Other important patient teaching includes maintaining a consistent intake of foods containing vitamin K and avoiding supplements that contain vitamin K. If a patient is taking warfarin, routine coagulation laboratory studies are needed. The frequency is patient dependent, not necessarily twice a week.

A patient with ineffective endocarditis develops sudden left leg pain with pallor, paresthesia, and a loss of peripheral pulses. What should the nurse's initial action be? a. Notify the HCP of the change in perfusion b. Start anticoagulant therapy with Iv heparin c. Elevate the leg to improve the venous return d. Position the patient in reverse Trendelenburg

A The patient may have acute arterial ischemia (sudden interruption in the arterial blood supply to the extremity), caused by an embolism from a cardiac thrombus that occurred as a complication of infective endocarditis. Manifestations include any or all of the 6 Ps: pain, pallor, paralysis, pulselessness, paresthesia, and poikilothermia. Without immediate intervention, ischemia may progress quickly to tissue necrosis and gangrene within a few hours. If the nurse detects these signs, the HCP should be notified immediately.

An older patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which action should the nurse take first? a. Check the blood pressure. b. Draw blood for laboratory testing. c. Assess for the presence of an abdominal bruit. d. Determine any family history of heart disease.

ANS: A Because the patient appears to be experiencing aortic dissection, the nurse's first action should be to determine the hemodynamic status by assessing blood pressure. The other actions may also be done, but they will not provide information to determine what interventions are needed immediately. DIF: Cognitive Level: Analyze (analysis) REF: 814 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment the patient has absent popliteal posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first? a. Notify the surgeon and anesthesiologist. b. Wrap both the legs in a warming blanket. c. Document the findings and recheck in 15 minutes. d. Compare findings to the preoperative assessment of the pulses.

ANS: A Lower extremity pulses may be absent for a short time after surgery because of vasospasm and hypothermia. Decreased or absent pulses together with a cool and mottled extremity may indicate embolization or graft occlusion. These findings should be reported to the surgeon immediately because this is an emergency situation. Because pulses are marked before surgery, the nurse would know whether pulses were present before surgery before notifying the health care providers about the absent pulses. Because the patient's symptoms may indicate graft occlusion or multiple emboli and a possible need to return to surgery, it is not appropriate to wait 15 minutes before taking action. A warming blanket will not improve the circulation to the patient's legs. DIF: Cognitive Level: Analyze (analysis) REF: 814 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

After teaching a patient with newly diagnosed Raynaud's phenomenon about how to manage the condition which action by the patient best demonstrates that the teaching has been effective? a. The patient exercises indoors during the winter months. b. The patient immerses hands in hot water when they turn pale. c. The patient takes pseudoephedrine (Sudafed) for cold symptoms. d. The patient avoids taking nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: A Patients should avoid temperature extremes by exercising indoors when it is cold. To avoid burn injuries, the patient should use warm rather than hot water to warm the hands. Pseudoephedrine is a vasoconstrictor and should be avoided. There is no reason to avoid taking NSAIDs with Raynaud's phenomenon. DIF: Cognitive Level: Apply (application) REF: 809 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

Which patient statement to the nurse is most consistent with the diagnosis of venous insufficiency? a. "I can't get my shoes on at the end of the day." b. "I can't ever seem to get my feet warm enough." c. "I have burning leg pains after I walk two blocks." d. "I wake up during the night because my legs hurt."

ANS: A Because the edema associated with venous insufficiency increases when the patient has been standing, shoes will feel tighter at the end of the day. The other patient statements are characteristic of peripheral artery disease.

When evaluating the discharge teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says, "I will a. use a heating pad on my feet at night to increase the circulation." b. buy some loose clothes that do not bind across my legs or waist." c. walk to the point of pain, rest, and walk again for at least 30 minutes 3 times a week." d. change my position every hour and avoid long periods of sitting with my legs crossed."

ANS: A Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. The other patient statements are correct and indicate that teaching has been successful.

The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action should the nurse perform first? a. Obtain vital signs. b. Teach wound care. c. Assess pedal pulses. d. Check the wound site.

ANS: A Bleeding is a possible complication after catheterization of the femoral artery, so the nurse's first action should be to assess for changes in vital signs that might indicate hemorrhage. The other actions are also appropriate but can be done after determining that bleeding is not occurring.

A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which group of drugs will the nurse plan to include when teaching about PAD management? a. Statins b. Antibiotics c. Thrombolytics d. Anticoagulants

ANS: A Research indicates that statin use by patients with PAD improves multiple outcomes. There is no research that supports the use of the other drug categories in PAD.

While working in the outpatient clinic the nurse notes that a patient has a history of intermittent claudication. Which statement by the patient would support this information? a. "When I stand too long, my feet start to swell." b. "My legs cramp when I walk more than a block." c. "I get short of breath when I climb a lot of stairs." d. "My fingers hurt when I go outside in cold weather."

ANS: B Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication. Finger pain associated with cold weather is typical of Raynaud's phenomenon. Shortness of breath that occurs with exercise is not typical of intermittent claudication, which is reproducible. Swelling associated with prolonged standing is typical of venous disease. DIF: Cognitive Level: Apply (application) REF: 803 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A patient has a 6-cm thoracic aortic aneurysm that was discovered during routine chest x-ray. When obtaining an admission history from the patient it will be most important for the nurse to ask about a. low back pain. b. trouble swallowing. c. abdominal tenderness. d. changes in bowel habits.

ANS: B Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the esophagus. The other symptoms will be important to assess for in patients with abdominal aortic aneurysms. DIF: Cognitive Level: Analyze (analysis) REF: 810 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

While working in the outpatient clinic, the nurse notes that a patient has a history of intermittent claudication. Which statement by the patient would support this information? a. "When I stand too long, my feet start to swell." b. "My legs cramp when I walk more than a block." c. "I get short of breath when I climb a lot of stairs." d. "My fingers hurt when I go outside in cold weather."

ANS: B Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication. Finger pain associated with cold weather is typical of Raynaud's phenomenon. Shortness of breath that occurs with exercise is not typical of intermittent claudication, which is reproducible. Swelling associated with prolonged standing is typical of venous disease.

The health care provider prescribes an infusion of heparin and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). The nurse will plan to a. decrease the infusion when the PTT value is 65 seconds. b. avoid giving IM medications to prevent localized bleeding. c. have vitamin K available in case reversal of the heparin is needed. d. monitor posterior tibial and dorsalis pedis pulses with the Doppler

ANS: B Intramuscular injections are avoided in patients receiving anticoagulation to prevent hematoma formation and bleeding from the site. A PTT of 65 seconds is within the therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by VTE.

The nurse who works in the vascular clinic has several patients with venous insufficiency scheduled today. Which patient should the nurse assign to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Patient who has been complaining of increased edema and skin changes in the legs b. Patient who needs wound care for a chronic venous stasis ulcer on the right lower leg c. Patient who has a history of venous thromboembolism and is complaining of dyspnea d. Patient who needs teaching about elastic compression stockings for venous insufficiency

ANS: B LPN education and scope of practice includes wound care. The other patients, which require more complex assessments or education, should be managed by the RN

A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is most accurate? a. "Taking two blood thinners greatly reduces the risk for another clot to form." b. "Enoxaparin will work right away, but warfarin takes several days to begin preventing clots." c. "Enoxaparin will start to dissolve the clot, and warfarin will prevent any more clots from forming." d. "Because of the risk for a blood clot in the lungs, it is important for you to take more than one blood thinner."

ANS: B Low molecular weight heparin (LMWH) is used because of the immediate effect on coagulation and discontinued once the international normalized ratio (INR) value indicates that the warfarin has reached a therapeutic level. LMWH has no thrombolytic properties. The use of two anticoagulants is not related to the risk for pulmonary embolism, and two are not necessary to reduce the risk for another VTE. Anticoagulants do not thin the blood.

The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) after hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says which of the following? a. "I should get a Medic Alert device stating that I take warfarin." b. "I should reduce the amount of green, leafy vegetables that I eat." c. "I will need routine blood tests to monitor the effects of the warfarin." d. "I will check with my health care provider before I begin any new drugs."

ANS: B Patients taking warfarin are taught to follow a consistent diet with regard to foods that are high in vitamin K, such as green, leafy vegetables. The other patient statements are accurate.

Which instructions should the nurse include in a teaching plan for an older patient newly diagnosed with peripheral artery disease (PAD)? a. "Exercise only if you do not experience any pain." b. "It is very important that you stop smoking cigarettes." c. "Try to keep your legs elevated whenever you are sitting." d. "Put elastic compression stockings on early in the morning."

ANS: B Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death. Circulation to the legs will decrease if the legs are elevated. Patients with PAD are taught to exercise to the point of feeling pain, rest, and then resume walking. Support hose are not used for patients with PAD.

After receiving change of shift report, which patient admitted to the emergency department should the nurse assess first? a. A 67-yr-old patient who has a gangrenous left foot ulcer with a weak pedal pulse b. A 50-yr-old patient who is complaining of sudden sharp and severe upper back pain c. A 39-yr-old patient who has right calf tenderness, redness, and swelling after a plane ride d. A 58-yr-old patient who is taking anticoagulants for atrial fibrillation and has black stools

ANS: B The patient's presentation of sudden sharp and severe upper back pain is consistent with dissecting thoracic aneurysm, which will require the most rapid intervention. The other patients also require rapid intervention but not before the patient with severe pain.

A 46-yr-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Which instructions should the nurse provide to the patient before discharge? a. Sitting at the work counter rather than standing, is recommended. b. Exercise, such as walking or jogging, can cause recurrence of varicosities. c. Elastic compression stockings should be applied before getting out of bed. d. Taking an aspirin daily will help prevent clots from forming around venous valves.

ANS: C Elastic compression stockings are applied with the legs elevated to reduce pressure in the lower legs. Walking is recommended to prevent recurrent varicosities. Sitting and standing are both risk factors for varicose veins and venous insufficiency. An aspirin a day is not adequate to prevent venous thrombosis and would not be recommended for a patient who had just had sclerotherapy. DIF: Cognitive Level: Apply (application) REF: 825 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair which assessment finding is most important for the nurse to communicate to the health care provider? a. Presence of flatus b. Hypoactive bowel sounds c. Maroon-colored liquid stool d. Abdominal pain with palpation

ANS: C Loose, bloody (maroon colored) stools at this time may indicate intestinal ischemia or infarction and should be reported immediately because the patient may need an emergency bowel resection. The other findings are normal on the first postoperative day after abdominal surgery. DIF: Cognitive Level: Analyze (analysis) REF: 813 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A young adult patient tells the health care provider about experiencing cold numb fingers when running during the winter, and Raynaud's phenomenon is suspected. The nurse will anticipate teaching the patient about tests for a. hyperglycemia. b. hyperlipidemia. c. autoimmune disorders. d. coronary artery disease.

ANS: C Secondary Raynaud's phenomenon may occur in conjunction with autoimmune diseases such as rheumatoid arthritis. Patients should be screened for autoimmune disorders. Raynaud's phenomenon is not associated with hyperlipidemia, hyperglycemia, or coronary artery disease. DIF: Cognitive Level: Apply (application) REF: 809 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider? a. Weak pedal pulses b. Absent bowel sounds c. Blood pressure of 138/88 mm Hg d. 25 mL of urine output over the past hour

ANS: C The blood pressure is typically kept at less than 120 mm Hg systolic to minimize extension of the dissection. The nurse will need to notify the health care provider so that -blockers or other antihypertensive drugs can be prescribed. The other findings are typical with aortic dissection and should also be reported but do not require immediate action. DIF: Cognitive Level: Analyze (analysis) REF: 815 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse performing an assessment of a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe would expect to find a. dilated superficial veins. b. swollen, dry, scaly ankles. c. prolonged capillary refill in all the toes. d. serosanguineous drainage from the ulcer

ANS: C Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease

Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? a. Erythema of right lower leg b. Complaint of right calf pain c. New onset shortness of breath d. Temperature of 100.4°F (38°C)

ANS: C New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as O2 administration and notification of the health care provider. The other findings are typical of VTE

When discussing risk factor modification for a patient who has a 5-cm abdominal aortic aneurysm the nurse will focus teaching on which patient risk factor? a. Male gender b. Turner syndrome c. Abdominal trauma history d. Uncontrolled hypertension

ANS: D All of the factors contribute to the patient's risk but only hypertension can potentially be modified to decrease the patient's risk for further expansion of the aneurysm. DIF: Cognitive Level: Apply (application) REF: 810 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Several hours after a patient had an open surgical repair of an abdominal aortic aneurysm the UAP reports to the nurse that urinary output for the past 2 hours has been 45 mL. The nurse notifies the health care provider and anticipates an order for a(n) a. hemoglobin count. b. additional antibiotic. c. serum creatinine level. d. increased IV infusion rate.

ANS: D The decreased urine output suggests decreased renal perfusion and monitoring of renal function is needed. There is no indication that infection is a concern, so antibiotic therapy and a WBC count are not needed. The IV rate may be increased because hypovolemia may be contributing to the patient's decreased urinary output. DIF: Cognitive Level: Apply (application) REF: 811 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Which topic should the nurse include in patient teaching for a patient with a venous stasis ulcer on the left lower leg? a. Need to increase carbohydrate intake b. Methods of keeping the wound area dry c. Purpose of prophylactic antibiotic therapy d. Application of elastic compression stockings

ANS: D Compression of the leg is essential to healing of venous stasis ulcers. High dietary intake of protein, rather than carbohydrates, is needed. Prophylactic antibiotics are not routinely used for venous ulcers. Moist dressings are used to hasten wound healing

A patient at the clinic says, "I always walk after dinner, but lately my leg cramps and hurts after just a few minutes of starting. The pain goes away after I stop walking, though." The nurse should a. look for the presence of tortuous veins bilaterally on the legs. b. ask about any skin color changes that occur in response to cold. c. assess for unilateral swelling, redness, and tenderness of either leg. d. palpate for the presence of dorsalis pedis and posterior tibial pulses.

ANS: D The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud's phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness indicate venous thromboembolism.

An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. The nurse should notify the health care provider and immediately a. apply a compression stocking to the leg. b. elevate the leg above the level of the heart. c. assist the patient in gently exercising the leg. d. keep the patient in bed in the supine position.

ANS: D The patient's history and clinical manifestations are consistent with acute arterial occlusion, and resting the leg will decrease the O2 demand of the tissues and minimize ischemic damage until circulation can be restored. 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

The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venous thromboembolism. Which action by the nurse to elevate the patient's feet is best? a. The patient is placed in the Trendelenburg position. b. Two pillows are positioned under the affected leg. c. The bed is elevated at the knee and pillows are placed under the feet. d. One pillow is placed under the thighs and two pillows are placed under the lower legs.

ANS: D The purpose of elevating the feet is to enhance venous flow from the feet to the right atrium, which is best accomplished by placing two pillows under the feet and one under the thighs. Placing the patient in the Trendelenburg position will lower the head below heart level, which is not indicated for this patient. Placing pillows under the calf or elevating the bed at the knee may cause blood stasis at the calf level.

The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain whenever she walks several blocks. The patient has type 1 diabetes and has smoked a pack of cigarettes every day for the past 40 years. The physician diagnoses intermittent claudication. The nurse should provide what instruction about long-term care to the client? A) "Be sure to practice meticulous foot care." B) "Consider cutting down on your smoking." C) "Reduce your activity level to accommodate your limitations." D) "Try to make sure you eat enough protein."

Ans: "Be sure to practice meticulous foot care." Feedback: The patient with peripheral vascular disease or diabetes should receive education or reinforcement about skin and foot care. Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing; therefore, meticulous foot care is essential. The patient should stop smoking—not just cut down—because nicotine is a vasoconstrictor. Daily walking benefits the patient with intermittent claudication. Increased protein intake will not alleviate the patient's symptoms.

A nurse in the rehabilitation unit is caring for an older adult patient who is in cardiac rehabilitation following an MI. The nurse's plan of care calls for the patient to walk for 10 minutes 3 times a day. The patient questions the relationship between walking and heart function. How should the nurse best reply? A) "The arteries in your legs constrict when you walk and allow the blood to move faster and with more pressure on the tissue." B) Walking increases your heart rate and blood pressure. Therefore your heart is under less stress." C) "Walking helps your heart adjust to your new arteries and helps build your self-esteem." D) "When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart."

Ans: "When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart." Feedback: Veins, unlike arteries, are equipped with valves that allow blood to move against the force of gravity. The legs have one-way bicuspid valves that prevent blood from seeping backward as it moves forward by the muscles in our legs pressing on the veins as we walk and increasing venous return. Leg arteries do constrict when walking, which allows the blood to move faster and with more pressure on the tissue, but the greater concern is increasing the flow of venous blood to the heart. Walking increases, not decreases, the heart' pumping ability, which increases heart rate and blood pressure and the hearts ability to manage stress. Walking does help the heart adjust to new arteries and may enhance self-esteem, but the patient had an MI—there are no "new arteries."

An older adult patient has been treated for a venous ulcer and a plan is in place to prevent the occurrence of future ulcers. What should the nurse include in this plan? A) Use of supplementary oxygen to aid tissue oxygenation B) Daily use of normal saline compresses on the lower limbs C) Daily administration of prophylactic antibiotics D) A high-protein diet that is rich in vitamins

Ans: A high-protein diet that is rich in vitamins Feedback: A diet that is high in protein, vitamins C and A, iron, and zinc is encouraged to promote healing and prevent future ulcers. Prophylactic antibiotics and saline compresses are not used to prevent ulcers. Oxygen supplementation does not prevent ulcer formation.

A medical nurse has admitted four patients over the course of a 12-hour shift. For which patient would assessment of ankle-brachial index (ABI) be most clearly warranted? A) A patient who has peripheral edema secondary to chronic heart failure B) An older adult patient who has a diagnosis of unstable angina C) A patient with poorly controlled type 1 diabetes who is a smoker D) A patient who has community-acquired pneumonia and a history of COPD

Ans: A patient with poorly controlled type 1 diabetes who is a smoker Feedback: Nurses should perform a baseline ABI on any patient with decreased pulses or any patient 50 years of age or older with a history of diabetes or smoking. The other answers do not apply.

The nurse is caring for a 72-year-old patient who is in cardiac rehabilitation following heart surgery. The patient has been walking on a regular basis for about a week and walks for 15 minutes 3 times a day. The patient states that he is having a cramp-like pain in the legs every time he walks and that the pain gets "better when I rest." The patient's care plan should address what problem? A) Decreased mobility related to VTE B) Acute pain related to intermittent claudication C) Decreased mobility related to venous insufficiency D) Acute pain related to vasculitis

Ans: Acute pain related to intermittent claudication Feedback: Intermittent claudication presents as a muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest. Patients with peripheral arterial insufficiency often complain of intermittent claudication due to a lack of oxygen to muscle tissue. Venous insufficiency presents as a disorder of venous blood reflux and does not present with cramp-type pain with exercise. Vasculitis is an inflammation of the blood vessels and presents with weakness, fever, and fatigue, but does not present with cramp-type pain with exercise. The pain associated with VTE does not have this clinical presentation.

A nurse on a medical unit is caring for a patient who has been diagnosed with lymphangitis. When reviewing this patient's medication administration record, the nurse should anticipate which of the following? A) Coumadin (warfarin) B) Lasix (furosemide) C) An antibiotic D) An antiplatelet aggregator

Ans: An antibiotic Feedback: Lymphangitis is an acute inflammation of the lymphatic channels caused by an infectious process. Antibiotics are always a component of treatment. Diuretics are of nominal use. Anticoagulants and antiplatelet aggregators are not indicated in this form of infection.

The triage nurse in the ED is assessing a patient who has presented with complaint of pain and swelling in her right lower leg. The patient's pain became much worse last night and appeared along with fever, chills, and sweating. The patient states, "I hit my leg on the car door 4 or 5 days ago and it has been sore ever since." The patient has a history of chronic venous insufficiency. What intervention should the nurse anticipate for this patient? A) Platelet transfusion to treat thrombocytopenia B) Warfarin to treat arterial insufficiency C) Antibiotics to treat cellulitis D) Heparin IV to treat VTE

Ans: Antibiotics to treat cellulitis Feedback: Cellulitis is the most common infectious cause of limb swelling. The signs and symptoms include acute onset of swelling, localized redness, and pain; it is frequently associated with systemic signs of fever, chills, and sweating. The patient may be able to identify a trauma that accounts for the source of infection. Thrombocytopenia is a loss or decrease in platelets and increases a patient's risk of bleeding; this problem would not cause these symptoms. Arterial insufficiency would present with ongoing pain related to activity. This patient does not have signs and symptoms of VTE.

A 79-year-old man is admitted to the medical unit with digital gangrene. The man states that his problems first began when he stubbed his toe going to the bathroom in the dark. In addition to this trauma, the nurse should suspect that the patient has a history of what health problem? A) Raynaud's phenomenon B) CAD C) Arterial insufficiency D) Varicose veins

Ans: Arterial insufficiency Feedback: Arterial insufficiency may result in gangrene of the toe (digital gangrene), which usually is caused by trauma. The toe is stubbed and then turns black. Raynaud's, CAD and varicose veins are not the usual causes of digital gangrene in the elderly.

A nurse is creating an education plan for a patient with venous insufficiency. What measure should the nurse include in the plan? A) Avoiding tight-fitting socks. B) Limit activity whenever possible. C) Sleep with legs in a dependent position. D) Avoid the use of pressure stockings.

Ans: Avoiding tight-fitting socks. Feedback: Measures taken to prevent complications include avoiding tight-fitting socks and panty girdles; maintaining activities, such as walking, sleeping with legs elevated, and using pressure stockings. Not included in the teaching plan for venous insufficiency would be reducing activity, sleeping with legs dependent, and avoiding pressure stockings. Each of these actions exacerbates venous insufficiency.

A nurse is admitting a 45-year-old man to the medical unit who has a history of PAD. While providing his health history, the patient reveals that he smokes about two packs of cigarettes a day, has a history of alcohol abuse, and does not exercise. What would be the priority health education for this patient? A) The lack of exercise, which is the main cause of PAD. B) The likelihood that heavy alcohol intake is a significant risk factor for PAD. C) Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD. D) Alcohol suppresses the immune system, creates high glucose levels, and may cause PAD.

Ans: Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD. Feedback: Tobacco is powerful vasoconstrictor; its use with PAD is highly detrimental, and patients are strongly advised to stop using tobacco. Sedentary lifestyle is also a risk factor, but smoking is likely a more significant risk factor that the nurse should address. Alcohol use is less likely to cause PAD, although it carries numerous health risks.

A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of HF and peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse should implement measures to prevent what complication? A) Aoritis B) Deep vein thrombosis C) Thoracic aortic aneurysm D) Raynaud's disease

Ans: Deep vein thrombosis Feedback: Although the exact cause of venous thrombosis remains unclear, three factors, known as Virchow's triad, are believed to play a significant role in its development: stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation. In this woman's case, she has venous stasis from immobility, vessel wall injury from PAD, and altered blood coagulation from HF. The cause of aoritis is unknown, but it has no direct connection to HF, PAD, or mobility issues. The greatest risk factors for thoracic aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to HF, PAD, or mobility issues. Raynaud's disease is a disorder that involves spasms of blood vessels and, again, no direct connection to HF, PAD, or mobility issues.

When assessing venous disease in a patient's lower extremities, the nurse knows that what test will most likely be ordered? A) Duplex ultrasonography B) Echocardiography C) Positron emission tomography (PET) D) Radiography

Ans: Duplex ultrasonography Feedback: Duplex ultrasound may be used to determine the level and extent of venous disease as well as its chronicity. Radiographs (x-rays), PET scanning, and echocardiography are never used for this purpose as they do not allow visualization of blood flow.

The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission assessment that the patient takes oral contraceptives. Consequently, the nurse's postoperative plan of care should include what intervention? A) Early ambulation and leg exercises B) Cessation of the oral contraceptives until 3 weeks postoperative C) Doppler ultrasound of peripheral circulation twice daily D) Dependent positioning of the patient's extremities when at rest

Ans: Early ambulation and leg exercises Feedback: Oral contraceptive use increases blood coagulability; with bed rest, the patient may be at increased risk of developing deep vein thrombosis. Leg exercises and early ambulation are among the interventions that address this risk. Assessment of peripheral circulation is important, but Doppler ultrasound may not be necessary to obtain these data. Dependent positioning increases the risk of venous thromboembolism (VTE). Contraceptives are not normally discontinued to address the risk of VTE in the short term.

The nurse is evaluating a patient's diagnosis of arterial insufficiency with reference to the adequacy of the patient's blood flow. On what physiological variables does adequate blood flow depend? Select all that apply. A) Efficiency of heart as a pump B) Adequacy of circulating blood volume C) Ratio of platelets to red blood cells D) Size of red blood cells E) Patency and responsiveness of the blood vessels

Ans: Efficiency of heart as a pump, Adequacy of circulating blood volume, Patency and responsiveness of the blood vessels Feedback: Adequate blood flow depends on the efficiency of the heart as a pump, the patency and responsiveness of the blood vessels, and the adequacy of circulating blood volume. Adequacy of blood flow does not primarily depend on the size of red cells or their ratio to the number of platelets.

How should the nurse best position a patient who has leg ulcers that are venous in origin? A) Keep the patient's legs flat and straight. B) Keep the patient's knees bent to 45-degree angle and supported with pillows. C) Elevate the patient's lower extremities. D) Dangle the patient's legs over the side of the bed.

Ans: Elevate the patient's lower extremities. Feedback: Positioning of the legs depends on whether the ulcer is of arterial or venous origin. With venous insufficiency, dependent edema can be avoided by elevating the lower extremities. Dangling the patient's legs and applying pillows may further compromise venous return.

A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. What is the most appropriate intervention for this diagnosis? A) Elevate his legs and arms above his heart when resting. B) Encourage the patient to engage in a moderate amount of exercise. C) Encourage extended periods of sitting or standing. D) Discourage walking in order to limit pain.

Ans: Encourage the patient to engage in a moderate amount of exercise. Feedback: The nursing diagnosis of altered peripheral tissue perfusion related to compromised circulation requires interventions that focus on improving circulation. Encouraging the patient to engage in a moderate amount of exercise serves to improve circulation. Elevating his legs and arms above his heart when resting would be passive and fails to promote circulation. Encouraging long periods of sitting or standing would further compromise circulation. The nurse should encourage, not discourage, walking to increase circulation and decrease pain.

A patient with advanced venous insufficiency is confined following orthopedic surgery. How can the nurse best prevent skin breakdown in the patient's lower extremities? A) Ensure that the patient's heels are protected and supported. B) Closely monitor the patient's serum albumin and prealbumin levels. C) Perform gentle massage of the patient's lower legs, as tolerated. D) Perform passive range-of-motion exercises once per shift.

Ans: Ensure that the patient's heels are protected and supported. Feedback: If the patient is on bed rest, it is important to relieve pressure on the heels to prevent pressure ulcerations, since the heels are among the most vulnerable body regions. Monitoring blood work does not directly prevent skin breakdown, even though albumin is related to wound healing. Massage is not normally indicated and may exacerbate skin breakdown. Passive range- of-motion exercises do not directly reduce the risk of skin breakdown.

The nurse is caring for a patient who is admitted to the medical unit for the treatment of a venous ulcer in the area of her lateral malleolus that has been unresponsive to treatment. What is the nurse most likely to find during an assessment of this patient's wound? A) Hemorrhage B) Heavy exudate C) Deep wound bed D) Pale-colored wound bed

Ans: Heavy exudate Feedback: Venous ulcerations in the area of the medial or lateral malleolus (gaiter area) are typically large, superficial, and highly exudative. Venous hypertension causes extravasation of blood, which discolors the area of the wound bed. Bleeding is not normally present.

The nurse caring for a patient with a leg ulcer has finished assessing the patient and is developing a problem list prior to writing a plan of care. What major nursing diagnosis might the care plan include? A) Risk for disuse syndrome B) Ineffective health maintenance C) Sedentary lifestyle D) Imbalanced nutrition: less than body requirements

Ans: Imbalanced nutrition: less than body requirements Feedback: Major nursing diagnoses for the patient with leg ulcers may include imbalanced nutrition: less than body requirements, related to increased need for nutrients that promote wound healing. Risk for disuse syndrome is a state in which an individual is at risk for deterioration of body systems owing to prescribed or unavoidable musculoskeletal inactivity. A leg ulcer will affect activity, but rarely to this degree. Leg ulcers are not necessarily a consequence of ineffective health maintenance or sedentary lifestyle.

While assessing a patient the nurse notes that the patient's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best respond to this assessment finding? A) Assess the patient's use of over-the-counter dietary supplements. B) Implement interventions relevant to arterial narrowing. C) Encourage the patient to increase intake of foods high in vitamin K. D) Adjust the patient's activity level to accommodate decreased coronary output.

Ans: Implement interventions relevant to arterial narrowing. Feedback: ABI is used to assess the degree of stenosis of peripheral arteries. An ABI of less than 1.0 indicates possible claudication of the peripheral arteries. It does not indicate inadequate coronary output. There is no direct indication for changes in vitamin K intake and OTC medications are not likely causative.

You are caring for a patient who is diagnosed with Raynaud's phenomenon. The nurse should plan interventions to address what nursing diagnosis? A) Chronic pain B) Ineffective tissue perfusion C) Impaired skin integrity D) Risk for injury

Ans: Ineffective tissue perfusion Feedback: Raynaud's phenomenon is a form of intermittent arteriolar vasoconstriction resulting in inadequate tissue perfusion. This results in coldness, pain, and pallor of the fingertips or toes. Pain is typically intermittent and acute, not chronic, and skin integrity is rarely at risk. In most cases, the patient is not at a high risk for injury.

A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the patient's left leg is visibly swollen and reddened. What is the nurse's most appropriate action? A) Administer a PRN dose of subcutaneous heparin. B) Inform the physician that the patient has signs and symptoms of VTE. C) Mobilize the patient promptly to dislodge any thrombi in the patient's lower leg. D) Massage the patient's lower leg to temporarily restore venous return.

Ans: Inform the physician that the patient has signs and symptoms of VTE. Feedback: VTE requires prompt medical follow-up. Heparin will not dissolve an established clot. Massaging the patient's leg and mobilizing the patient would be contraindicated because they would dislodge the clot, possibly resulting in a pulmonary embolism.

The nurse is taking a health history of a new patient. The patient reports experiencing pain in his left lower leg and foot when walking. This pain is relieved with rest. The nurse notes that the left lower leg is slightly edematous and is hairless. When planning this patient's subsequent care, the nurse should most likely address what health problem? A) Coronary artery disease (CAD) B) Intermittent claudication C) Arterial embolus D) Raynaud's disease

Ans: Intermittent claudication Feedback: A muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest is experienced by patients with peripheral arterial insufficiency. Referred to as intermittent claudication, this pain is caused by the inability of the arterial system to provide adequate blood flow to the tissues in the face of increased demands for nutrients and oxygen during exercise. The nurse would not suspect the patient has CAD, arterial embolus, or Raynaud's disease; none of these health problems produce this cluster of signs and symptoms.

The nurse is preparing to administer warfarin (Coumadin) to a client with deep vein thrombophlebitis (DVT). Which laboratory value would most clearly indicate that the patient's warfarin is at therapeutic levels? A) Partial thromboplastin time (PTT) within normal reference range B) Prothrombin time (PT) eight to ten times the control C) International normalized ratio (INR) between 2 and 3 D) Hematocrit of 32%

Ans: International normalized ratio (INR) between 2 and 3 Feedback: The INR is most often used to determine if warfarin is at a therapeutic level; an INR of 2 to 3 is considered therapeutic. Warfarin is also considered to be at therapeutic levels when the client's PT is 1.5 to 2 times the control. Higher values indicate increased risk of bleeding and hemorrhage, whereas lower values indicate increased risk of blood clot formation. Heparin, not warfarin, prolongs PTT. Hematocrit does not provide information on the effectiveness of warfarin; however, a falling hematocrit in a client taking warfarin may be a sign of hemorrhage.

The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers. The nurse's assessment should include which of the following components? Select all that apply. A) Location and type of pain B) Apical heart rate C) Bilateral comparison of peripheral pulses D) Comparison of temperature in the patient's legs E) Identification of mobility limitations

Ans: Location and type of pain, Bilateral comparison of peripheral pulses, Comparison of temperature in the patient's legs, Identification of mobility limitations Feedback: A careful nursing history and assessment are important. The extent and type of pain are carefully assessed, as are the appearance and temperature of the skin of both legs. The quality of all peripheral pulses is assessed, and the pulses in both legs are compared. Any limitation of mobility and activity that results from vascular insufficiency is identified. Not likely is there any direct indication for assessment of apical heart rate, although peripheral pulses must be assessed.

The nurse is caring for an acutely ill patient who is on anticoagulant therapy. The patient has a comorbidity of renal insufficiency. How will this patient's renal status affect heparin therapy? A) Heparin is contraindicated in the treatment of this patient. B) Heparin may be administered subcutaneously, but not IV. C) Lower doses of heparin are required for this patient. D) Coumadin will be substituted for heparin.

Ans: Lower doses of heparin are required for this patient. Feedback: If renal insufficiency exists, lower doses of heparin are required. Coumadin cannot be safely and effectively used as a substitute and there is no contraindication for IV administration.

A patient comes to the walk-in clinic with complaints of pain in his foot following stepping on a roofing nail 4 days ago. The patient has a visible red streak running up his foot and ankle. What health problem should the nurse suspect? A) Cellulitis B) Local inflammation C) Elephantiasis D) Lymphangitis

Ans: Lymphangitis Feedback: Lymphangitis is an acute inflammation of the lymphatic channels. It arises most commonly from a focus of infection in an extremity. Usually, the infectious organism is hemolytic streptococcus. The characteristic red streaks that extend up the arm or the leg from an infected wound outline the course of the lymphatic vessels as they drain. Cellulitis is caused by bacteria, which cause a generalized edema in the subcutaneous tissues surrounding the affected area. Local inflammation would not present with red streaks in the lymphatic channels. Elephantiasis is transmitted by mosquitoes that carry parasitic worm larvae; the parasites obstruct the lymphatic channels and results in gross enlargement of the limbs.

A nurse working in a long-term care facility is performing the admission assessment of a newly admitted, 85-year-old resident. During inspection of the resident's feet, the nurse notes that she appears to have early evidence of gangrene on one of her great toes. The nurse knows that gangrene in the elderly is often the first sign of what? A) Chronic venous insufficiency B) Raynaud's phenomenon C) VTE D) PAD

Ans: PAD Feedback: In elderly people, symptoms of PAD may be more pronounced than in younger people. In elderly patients who are inactive, gangrene may be the first sign of disease. Venous insufficiency does not normally manifest with gangrene. Similarly, VTE and Raynaud's phenomenon do not cause the ischemia that underlies gangrene.

The nurse is caring for a patient with a large venous leg ulcer. What intervention should the nurse implement to promote healing and prevent infection? A) Provide a high-calorie, high-protein diet. B) Apply a clean occlusive dressing once daily and whenever soiled. C) Irrigate the wound with hydrogen peroxide once daily. D) Apply an antibiotic ointment on the surrounding skin with each dressing change.

Ans: Provide a high-calorie, high-protein diet. Feedback: Wound healing is highly dependent on adequate nutrition. The diet should be sufficiently high in calories and protein. Antibiotic ointments are not normally used on the skin surrounding a leg ulcer and occlusive dressings can exacerbate impaired blood flow. Hydrogen peroxide is not normally used because it can damage granulation tissue.

The nurse is caring for a patient who returned from the tropics a few weeks ago and who sought care with signs and symptoms of lymphedema. The nurse's plan of care should prioritize what nursing diagnosis? A) Risk for infection related to lymphedema B) Disturbed body image related to lymphedema C) Ineffective health maintenance related to lymphedema D) Risk for deficient fluid volume related to lymphedema

Ans: Risk for infection related to lymphedema Feedback: Lymphedema, which is caused by accumulation of lymph in the tissues, constitutes a significant risk for infection. The patient's body image is likely to be disturbed, and the nurse should address this, but infection is a more significant threat to the patient's physiological well-being. Lymphedema is unrelated to ineffective health maintenance and deficient fluid volume is not a significant risk.

A nurse is closely monitoring a patient who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the patient's aneurysm? A) Sudden increase in blood pressure and a decrease in heart rate B) Cessation of pulsating in an aneurysm that has previously been pulsating visibly C) Sudden onset of severe back or abdominal pain D) New onset of hemoptysis

Ans: Sudden onset of severe back or abdominal pain Feedback: Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Impending rupture is not typically signaled by increased blood pressure, bradycardia, cessation of pulsing, or hemoptysis.

The nurse is assessing a woman who is pregnant at 27 weeks' gestation. The patient is concerned about the recent emergence of varicose veins on the backs of her calves. What is the nurse's best response? A) Facilitate a referral to a vascular surgeon. B) Assess the patient's ankle-brachial index (ABI) and perform Doppler ultrasound testing. C) Encourage the patient to increase her activity level. D) Teach the patient that circulatory changes during pregnancy frequently cause varicose veins.

Ans: Teach the patient that circulatory changes during pregnancy frequently cause varicose veins. Feedback: Pregnancy may cause varicosities because of hormonal effects related to decreased venous outflow, increased pressure by the gravid uterus, and increased blood volume. In most cases, no intervention or referral is necessary. This finding is not an indication for ABI assessment and increased activity will not likely resolve the problem.

A nurse is reviewing the physiological factors that affect a patient's cardiovascular health and tissue oxygenation. What is the systemic arteriovenous oxygen difference? A) The average amount of oxygen removed by each organ in the body B) The amount of oxygen removed from the blood by the heart C) The amount of oxygen returning to the lungs via the pulmonary artery D) The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood

Ans: The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood Feedback: The average amount of oxygen removed collectively by all of the body tissues is about 25%. This means that the blood in the vena cava contains about 25% less oxygen than aortic blood. This is known as the systemic arteriovenous oxygen difference. The other answers do not apply.

Graduated compression stockings have been prescribed to treat a patient's venous insufficiency. What education should the nurse prioritize when introducing this intervention to the patient? A) The need to take anticoagulants concurrent with using compression stockings B) The need to wear the stockings on a "one day on, one day off" schedule C) The importance of wearing the stockings around the clock to ensure maximum benefit D) The importance of ensuring the stockings are applied evenly with no pressure points

Ans: The importance of ensuring the stockings are applied evenly with no pressure points Feedback: Any type of stocking can inadvertently become a tourniquet if applied incorrectly (i.e., rolled tightly at the top). In such instances, the stockings produce rather than prevent stasis. For ambulatory patients, graduated compression stockings are removed at night and reapplied before the legs are lowered from the bed to the floor in the morning. They are used daily, not on alternating days. Anticoagulants are not always indicated in patients who are using compression stockings.

The nurse is providing care for a patient who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis? A) Numbness and tingling in the distal extremities B) Unequal peripheral pulses between extremities C) Visible clubbing of the fingers and toes D) Reddened extremities with muscle atrophy

Ans: Unequal peripheral pulses between extremities Feedback: PAD assessment may manifest as unequal pulses between extremities, with the affected leg cooler and paler than the unaffected leg. Intermittent claudication is far more common than sensations of numbness and tingling. Clubbing and muscle atrophy are not associated with PAD.

A patient presents to the clinic complaining of the inability to grasp objects with her right hand. The patient's right arm is cool and has a difference in blood pressure of more than 20 mm Hg compared with her left arm. The nurse should expect that the primary care provider may diagnose the woman with what health problem? A) Lymphedema B) Raynaud's phenomenon C) Upper extremity arterial occlusive disease D) Upper extremity VTE

Ans: Upper extremity arterial occlusive disease Feedback: The patient with upper extremity arterial occlusive disease typically complains of arm fatigue and pain with exercise (forearm claudication) and inability to hold or grasp objects (e.g., combing hair, placing objects on shelves above the head) and, occasionally, difficulty driving. Assessment findings include coolness and pallor of the affected extremity, decreased capillary refill, and a difference in arm blood pressures of more than 20 mm Hg. These symptoms are not closely associated with Raynaud's or lymphedema. The upper extremities are rare sites for VTE.

A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the pulse in the patient's left foot. How should the nurse proceed with assessment? A) Have the primary care provider order a CT. B) Apply a tourniquet for 3 to 5 minutes and then reassess. C) Elevate the extremity and attempt to palpate the pulses. D) Use Doppler ultrasound to identify the pulses.

Ans: Use Doppler ultrasound to identify the pulses. Feedback: When pulses cannot be reliably palpated, a hand-held continuous wave (CW) Doppler ultrasound device may be used to hear (insonate) the blood flow in vessels. CT is not normally warranted and the application of a tourniquet poses health risks and will not aid assessment. Elevating the extremity would make palpation more difficult.

An occupational health nurse is providing an educational event and has been asked by an administrative worker about the risk of varicose veins. What should the nurse suggest as a proactive preventative measure for varicose veins? A) Sit with crossed legs for a few minutes each hour to promote relaxation. B) Walk for several minutes every hour to promote circulation. C) Elevate the legs when tired. D) Wear snug-fitting ankle socks to decrease edema.

Ans: Walk for several minutes every hour to promote circulation. Feedback: A proactive approach to preventing varicose veins would be to walk for several minutes every hour to promote circulation. Sitting with crossed legs may promote relaxation, but it is contraindicated for patients with, or at risk for, varicose veins. Elevating the legs only helps blood passively return to the heart and does not help maintain the competency of the valves in the veins. Wearing tight ankle socks is contraindicated for patients with, or at risk for, varicose veins; socks that are below the muscles of the calf do not promote venous return, the socks simply capture the blood and promote venous stasis.

The prevention of VTE is an important part of the nursing care of high-risk patients. When providing patient teaching for these high-risk patients, the nurse should advise lifestyle changes, including which of the following? Select all that apply. A) High-protein diet B) Weight loss C) Regular exercise D) Smoking cessation E) Calcium and vitamin D supplementation

Ans: Weight loss, Regular exercise, Smoking cessation Feedback: Patients at risk for VTE should be advised to make lifestyle changes, as appropriate, which may include weight loss, smoking cessation, and regular exercise. Increased protein intake and supplementation with vitamin D and calcium do not address the main risk factors for VTE.

When teaching a patient about rest pain with PAD, what should the nurse explain as the cause of the pain a. Vasospasm of cutaneous arteries in the feet b. Decrease in blood flow to the nerves of the feet c. Increase in retrograde venous perfusion to the lower legs d. Constriction in blood flow to leg muscles during exercise

B Rest pain most often occurs in the forefoot or toes when arterial blood flow is insufficient to meet basic metabolic requirements of the distal tissues. Nerves transmit pain messages because of the tissue ischemia. Rest pain occurs more often at night because cardiac output tends to drop during sleep and the limbs are at the level of the heart. Patients often try to achieve some pain relief by dangling the leg over the side of the bed or sleeping in a chair to allow gravity to maximize blood flow.

A patient is admitted to the hospital with a diagnosis of abdominal aortic aneurysm. Which signs and symptoms would suggest that the aneurysm has ruptured? a. Rapid onset of shortness of breath and hemoptysis b. Sudden, severe low back pain and bruising along his flank c. Gradually increasing substernal chest pain and diaphoresis d. Sudden, patchy blue mottling on feet and toes and rest pain

B The manifestations of a ruptured abdominal aortic aneurysm include severe back pain, back or flank ecchymosis (Grey Turner's sign), and hypovolemic shock (tachycardia, hypotension, pale clammy skin, decreased urine output, altered level of consciousness, and abdominal tenderness).

A 50-year-old woman who weighs 95kg has a history of tobacco use, high blood pressure, high sodium intake, and sedentary lifestyle. Which is the most important risk factor for peripheral artery disease (PAD) to address in the nursing plan of care? a. Salt intake b. Tobacco use c. Excess weight d. Sedentary lifestyle

B The most important risk factor for peripheral artery disease is tobacco use. Other risk factors include increased levels of high-sensitivity C-reactive protein, diabetes, uncontrolled hypertension, family history, high triglyceride and lipid levels, hyperuricemia, increasing age, obesity, sedentary lifestyle, and stress.

Which patient is at highest risk for venous thromboembolism (VTE) a. A 62-yr-old man with spider veins who is having arthroscopic knee surgery b. A 32-yr-old woman who smokes, takes oral contraceptives, and is planning a trip to Europe c. A 26-yr-old woman who is 3 days postpartum and received maintenance IV fluids for 12 hours during her labor d. An active 72-yr-old man at home recovering from transurethral resection of the prostate for benign prostatic hyperplasia

B Three key factors (called Virchow's triad) that cause venous thrombosis are (1) venous stasis, (2) damage of the endothelium (inner lining of the vein), and (3) hypercoagulability of the blood. Patients at risk for venous thrombosis usually have predisposing conditions for these 3 disorders (see Table 37.8). The 32-yr-old woman has the highest risk: long trips without adequate exercise (venous stasis), tobacco use, and use of oral contraceptives.

Which clinical manifestations can the nurse expect to see in both patients with Buerger's disease and patients with Raynaud's phenomenon? (SATA) a. Intermittent low-grade fevers b. Sensitivity to cold temperatures c. Gangrenous ulcers on fingertips d. Color changes of fingers and toes e. Episodes of superficial vein thrombosis

B, C, D Buerger's disease and Raynaud's phenomenon have these manifestations in common: cold sensitivity, ischemic and gangrenous ulcers on fingertips, and color changes of the distal extremity (fingers or toes).

Which clinical findings should the nurse expect in a person with an acute low extremity VTE? (SATA) a. Pallor and coolness of foot and calf b. Mild to moderate calf pain and tenderness c. Grossly decreased or absent pedal pulses d. Unilateral edema and induration of the thigh e. Palpable cord along the superficial varicose vein

B, D The patient with lower extremity venous thromboembolism (VTE) may or may not have unilateral leg edema, extremity pain, a sense of fullness in the thigh or calf, paresthesia, warm skin, erythema, or a systemic temperature greater than 100.4 F (38 C). If the calf is involved, it may be tender to palpation

What are priority nursing interventions 8 hours after an abdominal aortic aneurysm repair? a. Accessing nutritional status and dietary preferences b. Initiating IV heparin and monitoring anticoagulation c. Administering IV fluids and watching kidney function d. Elevating legs and applying compression stockings

C Postoperative priorities include giving IV fluids and maintaining renal perfusion. An adequate blood pressure is important for maintaining graft patency, and administration of IV fluids and blood components (as indicated) is essential for adequate blood flow. The nurse should evaluate renal function by measuring hourly urine output and monitoring daily blood urea nitrogen (BUN) and serum creatinine levels. Irreversible renal failure may occur after aortic surgery, particularly in patients at high risk.

What is the first priority of interprofessional care for a patient with a suspected acute aortic distention? a. Reduce anxiety b. Monitor chest pain c. Control blood pressure d. Increase myocardial contractility

C The initial goals of therapy for acute aortic dissection without complications are blood pressure (BP) control and pain management. BP control reduces stress on the aortic wall by reducing systolic BP and myocardial contractility.

The nurse is planning care and teaching for a patient with venous leg ulcers. What is the most important patient action in healing and control of this condition? a. Following activity guidelines b. Using moist environment dressings c. Taking horse chestnut seed extract daily d. Applying graduated compression stockings

D Compression is essential for treating chronic venous insufficiency (CVI), healing venous ulcers, and preventing ulcer recurrence. Use of custom-fitted graduated compression stockings is an option for compression therapy

The patient comes to the HCP office with pain, edema, and warm skin on her lower left leg. What test should the nurse expect to be ordered first? a. Duplex ultrasound b. Complete blood count (CBC) c. Magnetic resonance imaging (MRI) d. Computed venography (phlebogram)

a. Duplex ultrasound With manifestations of a VTE, the Duplex ultrasound is most widely used to diagnose VTE by identifying where a thrombus is found and its extent. D-dimer may also be drawn to determine if a VTE exists.

The nurse evaluates that treatment for the patient with an uncomplicated aortic dissection is successful when what happens? a. Pain is relieved. b. Surgical repair is completed. c. BP is increased to normal range. d. Renal output is maintained at 30 mL/hr.

a. Pain is relieved. Relief of pain is a sign that the dissection has stabilized, and it may be treated conservatively for an extended time with drugs that lower the BP and decrease myocardial contractility. Surgery is usually indicated for Type A aortic dissection or if complications occur.

A patient has atrial fibrillation and develops an acute arterial occlusion at the iliac artery bifurcation. What are the 6 Ps of acute arterial occlusion the nurse may assess in this patient that require immediate notification of the HCP?

a. Pain; b. pallor; c. pulselessness; d. paresthesia; e. paralysis; f. poikilothermia. The HCP requires immediate notification to begin immediate intervention to prevent tissue necrosis and gangrene.

What are characteristic of vasospastic disease (Raynaud's phenomenon) (select all that apply)? a. Predominant in young females b. May be associated with autoimmune disorders c. Precipitated by exposure to cold, caffeine, and tobacco d. Involves small cutaneous arteries of the fingers and toes e. Inflammation of small and medium-sized arteries and veins f. Episodes involve white, blue, and red color changes of fingertips

a. Predominant in young females b. May be associated with autoimmune disorders c. Precipitated by exposure to cold, caffeine, and tobacco d. Involves small cutaneous arteries of the fingers and toes f. Episodes involve white, blue, and red color changes of fingertips

The surgery area calls the transfer report for a 68-year-old, postmenopausal, female patient who smokes and takes hormone therapy. She is returning to the floor after a lengthy hip replacement surgery. Which factors present in this patient increase her risk for developing venous thromboembolism (VTE) related to Virchow's triad (select all that apply)? a. Smoking b. IV therapy c. Dehydration d. Estrogen therapy e. Orthopedic surgery f. Prolonged immobilization

a. Smoking b. IV therapy d. Estrogen therapy e. Orthopedic surgery f. Prolonged immobilization This patient is a smoker and on hormone therapy, both of which increase blood hypercoagulability. She will have an IV, and her fractured hip can cause VTE by damaging the venous endothelium. She is an older patient who has had an orthopedic surgery and may have experienced prolonged immobility postinjury and through her "lengthy hip replacement surgery," which contributes to venous stasis. These are representative of Virchow's triad in this patient. The other options are also related to Virchow's triad but not present in this patient via the transfer report.

The nurse teaches the patient with any venous disorder that the best way to prevent venous stasis and increase venous return is to a. take short walks. b. sit with the legs elevated. c. frequently rotate the ankles. d. continuously wear elastic compression stockings.

a. take short walks. During walking, the muscles of the legs continuously knead the veins, promoting movement of venous blood toward the heart. Walking is the best measure to prevent venous stasis and will be increased gradually. Elevating the legs will decrease edema. The other methods will help venous return, but they do not provide the benefit that ambulation does.

The patient with VTE is receiving therapy with heparin and asks the nurse whether the drug will dissolve the clot in her leg. What is the best response by the nurse? a. "This drug will break up and dissolve the clot so that circulation in the vein can be restored." b. "The purpose of the heparin is to prevent growth of the clot or formation of new clots where the circulation is slowed." c. "Heparin won't dissolve the clot but it will inhibit the inflammation around the clot and delay the development of new clots." d. "The heparin will dilate the vein, preventing turbulence of blood flow around the clot that may cause it to break off and travel to the lungs."

b. "The purpose of the heparin is to prevent growth of the clot or formation of new clots where the circulation is slowed." Anticoagulant therapy with heparin or warfarin (Coumadin) does not dissolve clots but prevents propagation of the clot, development of new thrombi, and embolization. Clot lysis occurs naturally through the body's intrinsic fibrinolytic system or by the administration of thrombolytic agents

Which conditions characterize critical limb ischemia (select all that apply)? a. Cold feet b. Arterial leg ulcers c. Venous leg ulcers d. Gangrene of the leg e. No palpable peripheral pulses f. Rest pain lasting more than 2 weeks

b. Arterial leg ulcers d. Gangrene of the leg f. Rest pain lasting more than 2 weeks Arterial leg ulcers and/or gangrene of the leg caused by PAD and chronic ischemic rest pain lasting more than 2 weeks characterize critical limb ischemia. Optimal therapy is revascularization via bypass surgery.

The patient is diagnosed with a superficial vein thrombosis (SVT). Which characteristic should the nurse know about SVT? a. Embolization to lungs may result in death. b. Clot may extend to deeper veins if untreated. c. Vein is tender to pressure and there is edema. d. Typically found in the iliac, inferior, or superior vena cava.

b. Clot may extend to deeper veins if untreated. If left untreated, a superficial vein thrombosis (SVT) may extend to deeper veins and VTE may occur. VTE may embolize to the lungs and have tenderness to pressure and edema. SVTs usually occur in superficial leg veins and have tenderness, itchiness, redness, warmth, pain, inflammation, and induration along the course of the superficial vein

Priority Decision: A patient who is postoperative following repair of an AAA has been receiving IV fluids at 125 mL/hr continuously for the last 12 hours. Urine output for the last 4 hours has been 60 mL, 42 mL, 28 mL, and 20 mL, respectively. What is the priority action that the nurse should take? a. Monitor for a couple more hours. b. Contact the physician and report the decrease in urine output. c. Send blood for electrolytes, blood urea nitrogen (BUN), and creatinine. d. Decrease the rate of infusion to prevent blood leakage at the suture line.

b. Contact the HCP and report the decrease in urine output. The decreasing urine output is evidence that either the patient needs volume replacement or there is reduced renal blood flow. The HCP will want to be notified as soon as possible of this change in condition and will request results of daily blood urea nitrogen (BUN) and serum creatinine levels. The other options are incorrect.

When teaching the patient with PAD about modifying risk factors associated with the condition, what should the nurse emphasize? a. Amputation is the ultimate outcome if the patient does not alter lifestyle behaviors. b. Modifications will reduce the risk of other atherosclerotic conditions such as stroke. c. Risk-reducing behaviors initiated after angioplasty can stop the progression of the disease. d. Maintenance of normal body weight is the most important factor in controlling arterial disease

b. Modifications will reduce the risk of other atherosclerotic conditions such as stroke. PAD occurs as a result of atherosclerosis and the risk factors are the same as for other diseases associated with atherosclerosis, such as CAD, cerebrovascular disease, and aneurysms. Major risk factors are tobacco use, hyperlipidemia, elevated C-reactive protein, diabetes, obesity, and uncontrolled hypertension. The risk for amputation is high in patients with severe occlusive disease, but this is not the best approach to encourage patients to make lifestyle modifications.

What are characteristics of PAD (select all that apply)? a. Pruritus b. Thickened, brittle nails c. Dull ache in calf or thigh d. Decreased peripheral pulses e. Pallor on elevation of the legs f. Ulcers over bony prominences on toes and feet

b. Thickened, brittle nails d. Decreased peripheral pulses e. Pallor on elevation of the legs f. Ulcers over bony prominences on toes and feet PAD is manifested as thick, brittle nails; decreased peripheral pulses; pallor when the legs are elevated; ulcers over bony prominences on the toes and feet; and paresthesia. The other options are characteristic of venous disease and paresthesia could occur with venous thromboembolism (VTE).

A patient with PAD has a nursing diagnosis of ineffective peripheral tissue perfusion. What should be included in the teaching plan for this patient (select all that apply)? a. Apply cold compresses when the legs become swollen. b. wear protective footwear and avoid hot or cold extremes. c. Walk at least 30 minutes per day, at least 3 times per week. d. Use nicotine replacement therapy as a substitute for smoking. e. Inspect lower extremities for pulses, temperature, and any injury.

b. wear protective footwear and avoid hot or cold extremes. c. Walk at least 30 minutes per day, at least 3 times per week. e. Inspect lower extremities for pulses, temperature, and any injury. Protecting feet and legs from injury is important. Walking exercise increases oxygen extraction in the legs and improves skeletal muscle metabolism. The patient with PAD should walk at least 30 minutes a day, at least 3 times per week. Exercise should be stopped when pain occurs and resumed when the pain subsides. The lower extremities should be assessed at regular intervals for changes. Cold compresses and nicotine in all forms causes vasoconstriction and should be avoided.

Following teaching about medications for PAD, the nurse determines that additional instruction is necessary when the patient says, a) "I should take one aspirin a day to prevent clotting in my legs." b) "The lisinopril I use for my BP may help me walk further without pain." c) "I will need to have frequent blood tests to evaluate the effect of the Trental I will be taking." d) "Pletal should help me be able to increase my walking distance and speed and help prevent pain in the legs."

c) "I will need to have frequent blood tests to evaluate the effect of the Trental I will be taking." Pentoxifylline allows blood cells to pass through small vessels, but there are no blood tests related to it. Warfarin (Coumadin), which needs international normalized ration (INR) blood tests, is not recommended for prevention of cardiovascular disease (CVD) events in patients with PAD. All the other statements are correct in relation to treatment of PAD.

Priority Decision: Following an ascending aortic aneurysm repair, what is an important finding that the nurse should report immediately to the health care provider? a. Shallow respirations and poor coughing b. Decreased drainage from the chest tubes c. A change in level of consciousness (LOC) and inability to speak d. Lower extremity pulses that are decreased from the preoperative baseline

c. A change in level of consciousness (LOC) and inability to speak During repair of an ascending aortic aneurysm, the blood supply to the carotid arteries may be interrupted, leading to neurologic complications manifested by a decreased level of consciousness (LOC) and altered pupil responses to light as well as changes in facial symmetry, speech, upper extremity movement, and hand grasp quality. The thorax is opened for ascending aortic surgery, and shallow breathing, poor cough, and decreasing chest drainage are expected. Lower limb pulses may normally be decreased or absent for a short time following surgery.

During care of the patient following femoral bypass graft surgery, the nurse immediately notifies the health care provider if the patient experiences... a. fever and redness at the incision site b. 2+ edema of the extremity and pain at the incision site c. A loss of palpable pulses and numbness and tingling of the feet d. increasing ankle-brachial indices and serous drainage from the incision

c. A loss of palpable pulses and numbness and tingling of the feet Loss of palpable pulses, numbness and tingling of the extremity, extremity pallor, cyanosis, or cold are indications of occlusion of the bypass graft and need immediate medical attention. Pain, redness, and serous drainage at the incision site are expected postoperatively. Ankle brachial index measurements are not recommended because of increased risk for graft thrombosis, but this would decrease with occlusion

What is the most important measure in the treatment of venous leg ulcers? a. Elevation of the affected leg b. Application of topical antibiotics c. Graduated compression stockings d. Application of moist to dry dressings

c. Graduated compression stockings Although leg elevation, moist dressings, and systemic antibiotics are useful in treatment of venous stasis ulcers, the most important factor is compression, which minimizes venous stasis, venous hypertension, and edema and prevents recurrence. Compression may be applied with various methods including stockings, elastic bandages or wraps, or a Velcro wrap, among others.

Delegation Decision: The nursing care area is very busy with new surgical patients. Which care could the RN delegate to the unlicensed assistive personnel (UAP) for a patient with VTE? a. Assess the patient's use of herbs. b. Measure the patient for elastic compression stockings. c. Remind the patient to flex and extend the legs and feet every 2 hours d. Teach the patient to call emergency medical services (EMS) with signs of pulmonary embolus

c. Remind the patient to flex and extend the legs and feet every 2 hours The RN could delegate to the UAP the task to remind the patient to flex and extend the legs and feet every 2 hours while in bed. Measuring for elastic compression stockings may be delegated to the LPN. The RN must assess and teach the patient.

When obtaining a health history from a 72 year old man with peripheral arterial disease (PAD) of the lower extremities, the nurse asks about a history of related conditions, including? a) Venous thrombosis b) Venous stasis ulcers c) Pulmonary embolism d) Coronary artery disease

d) Coronary artery disease Regardless of the location, atherosclerosis is responsible for peripheral arterial disease (PAD) and is related to other cardiovascular disease and its risk factors, such as coronary artery disease (CAD) and carotid artery disease. Venous thrombosis, venous stasis ulcers, and pulmonary embolism are diseases of the veins and are not related to atherosclerosis.

A patient with VTE is to be discharged on long-term warfarin (Coumadin) therapy and is taught about prevention and continuing treatment of VTE. The nurse determines that discharge teaching for the patient has been effective when the patient makes which statement? a. "I should expect that Coumadin will cause my stools to be somewhat black." b. "I should avoid all dark green and leafy vegetables while I am taking Coumadin." c. "Massaging my legs several times a day will help increase my venous circulation." d. "Swimming is a good activity to include in my exercise program to increase my circulation."

d. "Swimming is a good activity to include in my exercise program to increase my circulation." Exercise programs for patients recovering from VTE should emphasize swimming, which is particularly beneficial because of the gentle, even pressure of the water. Coumadin will not blacken stools. If this occurs, it could be a sign of gastrointestinal bleeding. Dark green and leafy vegetables have high amounts of vitamin K and should not be increased during Coumadin therapy, but they do not need to be restricted. The legs must not be massaged because of the risk for dislodging any clots that may be present.

A thoracic aortic aneurysm is found when a patient has a routine chest x-ray. The nurse anticipates that additional diagnostic testing to determine the size and structure of the aneurysm will include which test? a. Angiography b. Ultrasonography c. Echocardiography d. Computed tomography (CT) scan

d. Computed tomography (CT) scan A CT scan is the most accurate test to determine the length and diameter of the aneurysm and whether a thrombus is present. The other tests may also be used, but the CT scan yields the most descriptive results.

To help prevent embolization of the thrombus in a patient with acute VTE and severe edema and limb pain, what should the nurse teach the patient to do first? a. Dangle the feet over the edge of the bed q2-3hr. b. Ambulate around the bed three to four times a day. c. Keep the affected leg elevated above the level of the heart. d. Maintain bed rest until edema is relieved and anticoagulation is established.

d. Maintain bed rest until edema is relieved and anticoagulation is established. With acute VTE, prevention of emboli formation, decreased edema and pain can be achieved initially by bed rest and limiting movement of the involved extremity. Ambulation will be the next priority. Dangling the legs promotes venous stasis and further clot formation. Elevating the affected limb will promote venous return, but it does not prevent embolization.