chapter 30- med surg
The nurse is assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse include in the education of the patient during ambulation? "As soon as you feel pain, we will go back and elevate your legs." "If you feel pain during the walk, keep walking until the end of the hallway is reached." "Walk to the point of pain, rest until the pain subsides, then resume ambulation." "If you feel any discomfort, stop and we will use a wheelchair to take you back to your room."
"Walk to the point of pain, rest until the pain subsides, then resume ambulation."
Health teaching includes advising patients on ways to reduce PAD. The nurse should always emphasize that the strongest risk factor for the development of atherosclerotic lesions is: Cigarette smoking. Lack of exercise. Obesity. Stress.
cigarette smoking
A nurse suspects the presence of an abdominal aortic aneurysm. What assessment data would the nurse correlate with a diagnosis of abdominal aortic aneurysm? (Select all that apply.) A pulsatile abdominal mass Low back pain Lower abdominal pain Decreased bowel sounds
a pulsatile abdominal mass low back pain lower abdominal pain
Which aneurysm results in bleeding into the layers of the arterial wall? Saccular Dissecting False Anastomotic
dissecting
To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a 45-degree angle and then have the client sit up. The nurse suspects arterial insufficiency if the assessment reveals: elevational rubor. no rubor for 10 seconds after the maneuver. elevational pallor. a 30-second filling time for the veins.
elevational pallor
A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued? Activated partial thromboplastin time (aPPT) is half of the control value Prothrombin time (PT) is 0.5 times normal. International normalized ratio (INR) is 2.5. K+ level is 3.5.
international normalized ration (INR) is 2.5
The nurse is caring for a patient with venous insufficiency. For what should the nurse assess the patient's lower extremities? Rubor Cellulitis Dermatitis Ulceration
ulceration
A client admitted to the medical-surgical unit with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are needed. Which response by the nurse is accurate? "Administration of two anticoagulants decreases the risk of recurrent venous thrombosis." "Enoxaparin will dissolve the clot, and warfarin will prevent any more clots from occurring." "The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect." "Because of the potential for a pulmonary embolism, it is important for you to take at least two anticoagulants."
"The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect."
The physician prescribed a Tegapore dressing to treat a venous ulcer. What should the nurse expect that the ankle-brachial index (ABI) will be if the circulatory status is adequate? 0.10 0.25 0.35 0.50
0.50
A nursing instructor is discussing the diagnosis of intermittent claudication with students. To determine whether the students understand the pathophysiology of the disease, the instructor asks, "What percentage of the arterial lumen must be obstructed before intermittent claudication is experienced?" What answer should the students give? 20 30 40 50
50
In a client with a bypass graft, the distal outflow vessel must have at least what percentage patency for the graft to remain patent? 20 30 40 50
50
Which of the following is accurate regarding the effects of nicotine and tobacco smoke on the body? Select all that apply. Causes vasospasm Reduces circulation to the extremities Impairs transport and cellular use of oxygen Increases blood viscosity Decreases blood viscosity
Impairs transport and cellular use of oxygen Reduces circulation to the extremities Increases blood viscosity Causes vasospasm
Heparin therapy is usually considered therapeutic when the activated partial thromboplastin time (aPTT) is how many times higher than a normal value? 0.5 to 1.5 1.5 to 2.5 2.5 to 3.5 3.5 to 4.5
1.5-2.5
A client with peripheral arterial disease asks the nurse about using a heating pad to warm the feet. The nurse's best response is which of the following? "It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet." "A heating pad to your feet is fine as long as the temperature stays below 105 degrees F." "A heating pad to your feet is a good idea because it increases the metabolic rate." "It is better to soak your feet in hot water as long as the water temperature is below 110 degrees F."
"It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet."
A client is being discharged home with a venous stasis ulcer on the right lower leg. Which topic will the nurse include in client teaching before discharge? Adequate carbohydrate intake Application of graduated compression stockings Prophylactic antibiotic therapy Methods of keeping the wound area dry
Application of graduated compression stockings
Which of the following assessment results is considered a major risk factor for PAD? LDL of 100 mg/dL BP of 160/110 mm Hg Cholesterol of 200 mg/dL Triglyceride level of 150 mg/dL
BP of 160/110 mmHg
A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? Urine output of 15 ml/hour and 2+ hematuria Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute Urine output of 150 ml/hour and heart rate of 45 beats/minute Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute
Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute
Which statement is accurate regarding Raynaud disease? The disease generally affects the client trilaterally. It affects more than two digits on each hand or foot. It is most common in men 16 to 40 years of age. Episodes may be triggered by unusual sensitivity to cold.
Episodes may be triggered by unusual sensitivity to cold.
Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity? Intermittent claudication Acute limb ischemia Dizziness Vertigo
intermittent claudication - aching or cramping in a muscle that occurs with the same degree of exercise or activity and is releived with rest
A community health nurse teaches a group of older adults about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which statement? "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." "I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels." "The older I get the higher my risk for peripheral arterial disease gets." "Because my family is from Italy, I have a higher risk of developing peripheral arterial disease."
I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."
A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following? Arterial insufficiency Venous insufficiency Neither venous nor arterial Trauma
arterial insufficiency
A pregnant client who developed deep vein thrombosis (DVT) in her right leg is receiving heparin I.V. on the medical floor. Physical therapy is ordered to maintain her mobility and prevent additional DVT. A nursing assistant working on the medical unit helps the client with bathing, range-of-motion exercises, and personal care. Which collaborative multidisciplinary considerations should the care plan address? The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include sequential compression device application and strict bed rest. The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising. The client is at risk for developing another DVT; therefore, the care plan should include reporting redness, tenderness, or edema in the other lower extremity. The client is pregnant and receiving I.V. heparin, placing her at risk for premature labor; therefore, the care plan should include reporting signs of premature labor.
The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising.
Which assessment finding by the nurse is the most significant finding suggestive of aortic aneurysm? High blood pressure Severe back pain Abdomen bruit Nausea and vomiting
abdomen bruit-
The most common site of aneurysm formation is in the: abdominal aorta, just below the renal arteries. ascending aorta, around the aortic arch. descending aorta, beyond the subclavian arteries. aortic arch, around the ascending and descending aorta
abdominal aorta, just below the renal arteries
A patient is admitted to a special critical care unit for the treatment of an arterial thrombus. The nurse is aware that the preferred drug of choice for clot removal, unless contraindicated, would be: Alteplase. Reteplase. Urokinase. Streptokinase
alteplase-
Which aneurysm occurs as a result of infection at arterial suture or graft sites? Anastomotic False Dissecting Saccular
anastomotic- occurs as a result of infection, arterial wall failure, and suture or graft failure
To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the: Inside of the ankle just above the heel. Exterior surface of the foot near the heel. Outside of the foot just below the heel. Anterior surface of the foot near the ankle joint.
anterior surface of the foot near the ankle joint
A client in the emergency department states, "I have always taken a morning walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." Based on this statement, which priority assessment should the nurse complete? Check for the presence of tortuous veins bilaterally on the legs. Ask about any changes in skin color that occur in response to cold. Attempt to palpate the dorsalis pedis and posterior tibial pulses. Assess for unilateral swelling and tenderness of either leg.
attempt to palpate the dorsalis pedis and posterior tibial pulses
Which of the following is a characteristic of an arterial ulcer? Border regular and well demarcated Brawny edema Ankle-brachial index (ABI) > 0.90 Edema may be severe
border regular and well demarcated
Pentoxifylline (Trental) is a medication used for which of the following conditions? Claudication Thromboemboli Hypertension Elevated triglycerides
claudication
A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following? Constant, intense back pain and falling blood pressure Constant, intense headache and falling blood pressure Higher than normal blood pressure and falling hematocrit Slow heart rate and high blood pressure
constant, intense back pain and falling of blood pressure
The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is air plethysmography. contrast phlebography. lymphangiography. lymphoscintigraphy.
contrast phlebography- quantifies venous reflux and calf muscle pump ejection lymphangiography- contrast media are injected into the lymph system lymphoscintigraphy- a radioactive labeled colloid is injected into the lymph system
Which observation regarding ulcer formation on the client's lower extremity indicates to the nurse that the ulcer is a result of venous insufficiency? Large and superficial Though superficial, is very painful Base is pale to black Is deep, involving the joint space
large and superficial
The most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program is that this form of exercise: reduces stress. aids in weight reduction. increases high-density lipoprotein (HDL) level. decreases venous congestion.
decrease venous congestion
A patient who had a colon resection 3 days ago is complaining of discomfort in the left calf. How should the nurse assess Homan's sign to determine if the patient may have a thrombus formation in the leg? Dorsiflex the foot while the leg is elevated to check for calf pain. Elevate the patient's legs for 20 minutes and then lower them slowly while checking for areas of inadequate blood return. Extend the leg, plantar flex the foot, and check for the patency of the dorsalis pedis pulse. Lower the patient's legs and massage the calf muscles to note any areas of tenderness.
dorsiflex the foot while the leg is elevated to check for calf pain
A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency? Elevate the legs periodically for at least an hour. Avoid foods with iodine. Elevate the legs periodically for at least 15 to 20 minutes. Refrain from sexual activity for a week.
elevate the legs periodically for at least 15 to 20 minutes
A patient is having an angiography to detect the presence of an aneurysm. After the contrast is administered by the interventionist, the patient begins to complain of nausea and difficulty breathing. What medication is a priority to administer at this time? Metoprolol (Lopressor) Epinephrine Hydrocortisone (Solu-Cortef) Cimetidine (Tagamet)
epinephrine
Which class of medication lyses and dissolves thrombi? Fibrinolytic Anticoagulant Platelet inhibitors Factor XA inhibitors
fibrinolytic
A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: encouraging ambulation to prevent pooling of blood. providing warmth to the extremity. elevating the extremity to prevent pooling of blood. forcing blood into the deep venous system.
forcing blood into the deep venous system
Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of: Hemorrhage. Thrombosis of the graft. Decreased motor function. Stent dislodgement.
hemorrhage
A patient with diabetes is being treated for a wound on the lower extremity that has been present for 30 days. What option for treatment is available to increase diffusion of oxygen to the hypoxic wound? Surgical debridement Enzymatic debridement Hyperbaric oxygen Vacuum-assisted closure device
hyperbaric oxygen
The nurse is caring for a patient who has started anticoagulant therapy with warfarin (Coumadin). When does the nurse understand that therapeutic benefits will begin? Within 12 hours Within the first 24 hours In 2 days
in 3 to 5 days
Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending? Increased abdominal and back pain Decreased pulse rate and blood pressure Retrosternal back pain radiating to the left arm Elevated blood pressure and rapid respirations
increased abdominal and back pain
The nurse teaches the client with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes vasospasm. slowed heart rate. depression of the cough reflex. diuresis.
vasospasm
Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect: pallor and coolness of the left foot. a decrease in the left pedal pulse. loss of hair on the lower portion of the left leg. left calf circumference 1" (2.5 cm) larger than the right.
left calf circumference 1" (2.5 cm) larger than the right.
A nurse is completing an assessment on a client and discovers an enlarged, red, and tender lymph node. The nurse will describe and document the lymph node using which term? Lymphadenitis Lymphangitis Lymphedema Elephantiasis
lymphadenitis
A client is diagnosed with peripheral arterial disease. Review of the client's chart shows an ankle-brachial index (ABI) on the right of 0.45. This indicates that the right foot has which of the following? Moderate to severe arterial insufficiency No arterial insufficiency Very mild arterial insufficiency Tissue loss to that foot
moderate to severe arterial insufficiency
The nurse is performing wound care for a patient with a necrotic sacral wound. The prescribed treatment is isotonic saline solution with fine mesh gauze and a dry dressing to cover. What type of debridement is the nurse performing? Surgical debridement Nonselective debridement Enzymatic debridement Selective debridement
nonselective debridement
A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment? Numbness, cool skin temperature, and pallor Swelling, warm skin temperature, and drainage Numbness, warm skin temperature, and redness Redness, cool skin temperature, and swelling
numbness, cool skin temperature, and pallor
A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities? Keep the extremities elevated slightly. Participate in a regular walking program. Use a heating pad to promote warmth. Massage the calf muscles if pain occurs.
participate in a regular walking program
A nurse is caring for a client following an arterial vascular bypass graft in the leg. What should the nurse plan to assess over the next 24 hours? Peripheral pulses every 15 minutes after surgery Ankle-arm indices every 12 hours Blood pressure every 2 hours Color of the leg every 4 hours
peripheral pusles every 15 minutes after surgery
While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first? Decrease the heparin infusion rate. Prepare to administer protamine sulfate. Monitor the partial thromboplastin time (PTT). Start an I.V. infusion of dextrose 5% in water (D5W).
prepare to administer protamine sulfate
A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs? Bleeding time Platelet count Prothrombin time (PT) Partial thromboplastin time (PTT)
prothrombin time PT- determines a clients response to oral anticoagulant therapy, measures the time required for a fibrin clot to form
A client with systemic lupus erythematosus (SLE) complains that his hands become pale, blue, and painful when exposed to the cold. What disease should the nurse cite as an explanation for these signs and symptoms? Peripheral vascular disease Raynaud's disease Arterial occlusive diseases Buerger's disease
raynauds disease
A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important? History of increased aspirin use Recent pelvic surgery An active daily walking program A history of diabetes mellitus
recent pelvic surgery
When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe? Painful skin that is swollen and pale in color Cold, red skin Small, localized blackened area of skin Red, swollen skin with inflammation spreading to surrounding tissues
red, swollen skin with inflammation spreading to surrounding tissues- cellulitis is an inflammation of soft tissues
A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions? Decreasing blood pressure and increasing mobility Increasing blood pressure and reducing mobility Stabilizing heart rate and blood pressure and easing anxiety Increasing blood pressure and monitoring fluid intake and output
stabilizing heart rate and blood pressure and easing anxiety
A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client? Stop smoking. Keep your feet elevated above your heart. Wear antiembolic stockings daily to assist with blood return to the heart. Do not cross your legs for more than 30 minutes at a time.
stop smoking
On a routine visit to the physician, a client with chronic arterial occlusive disease reports that he's stopped smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, which additional measure should the nurse recommend? Taking daily walks Engaging in anaerobic exercise Reducing daily fat intake to less than 45% of total calories Abstaining from foods that increase levels of high-density lipoproteins (HDLs)
taking daily walks
What should the nurse do to manage the persistent swelling in a client with severe lymphangitis and lymphadenitis? Teach the client how to apply an elastic sleeve Inform the physician if the client's temperature remains low Avoid elevating the area Offer cold applications to promote comfort and to enhance circulation
teach the client how to apply an elastic sleeve
A client with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which is the most likely cause? The aneurysm has become obstructed. The aneurysm may be preparing to rupture. The client is experiencing inflammation of the aneurysm. The client is experiencing normal sensations associated with this condition.
the aneurysm may be preparing to rupture
A nurse and physician are preparing to visit a hospitalized client with peripheral arterial disease. As you approach the client's room, the physician asks if the client has reported any intermittent claudication. The client has reported this symptom. The nurse explains to the physician which of the following details? The client can walk about 50 feet before getting pain in the right lower leg. The client's fingers tingle when left in one position for too long. The client experiences shortness of breath after walking about 50 feet. The client's legs awaken him during the night with itching.
the client can walk about 50 feet before getting pain in the right lower leg
The most important factor regulating the caliber of blood vessels, which determines resistance to flow, is: Hormonal secretion. Independent arterial wall activity. The influence of circulating chemicals. The sympathetic nervous system.
the sympathetic nervous system
What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue? Loose and wrinkled skin Ulcers and infection in the edematous area Evident scarring Cyanosis
ulcers and infection in the edematous area
A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gaiter area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect? Arterial insufficiency Venous insufficiency Neither venous nor arterial insufficiency Trauma
venous insufficiency- symptoms include present pedal pulses, edema, pigmentation in gaiter area and reddish blue color