MS2 Ch 30
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?
"Walk to the point of pain, rest until the pain subsides, then resume ambulation Explanation: The nurse instructs the patient to walk to the point of pain, rest until the pain subsides, and then resume walking so that endurance can be increased as collateral circulation develops. Pain can serve as a guide in determining the appropriate amount of exercise.
When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of:
1.5 to 2.5 times the baseline control Explanation: A normal PTT level is 21 to 35 seconds. A reading of more than 100 seconds indicates a significant risk of hemorrhage.
Approximately what percentage of the arterial lumen must be obstructed before intermittent claudication is experienced?
50 Explanation: Typically, about 50% of the arterial lumen or 75% of the cross-sectional area must be obstructed before intermittent claudication is experienced.
The nurse is assessing a client with severe hypertension. Which symptom indicates to the nurse that the client is experiencing dissection of the aorta?
A ripping sensation in the chest Explanation: Aortic dissections are commonly associated with poorly controlled hypertension. Dissection is caused by rupture in the intimal layer. A rupture may occur through adventitia or into the lumen through the intima, allowing blood to reenter the main channel and resulting in chronic dissection or occlusion of branches of the aorta. The onset of symptoms is usually sudden and described as severe, persistent pain that feels like tearing or ripping. An aortic dissection does not cause pain and numbness of the left arm. Pain when flexing the neck forward is not associated with an aortic dissection. An aortic dissection does not cause a headache.
The most common site of aneurysm formation is in the:
Abdominal aorta, just below the renal arteries Explanation: About 75% of aneurysms occur in the abdominal aorta, just below the renal arteries (Debarked type I aneurysms). Debarked type II aneurysms occur in the aortic arch around the ascending and descending aorta, whereas Debarked type III aneurysms occur in the descending aorta, beyond the subclavian arteries.
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 Explanation: Characteristics of arterial insufficiency ulcers include location at the tips of the toes, extreme painfulness, and circular shape with pale to black ulcer bases. Ulcers caused by venous insufficiency will be irregular in shape, minimal pain if superficial (can be painful), and usually located around the ankles or the anterior tibial area.
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?
Attempt to palpate the dorsalis pedis and posterior tibial pulse Explanation: Intermittent claudication is a sign of peripheral arterial insufficiency. The nurse should assess for other clinical manifestations of peripheral arterial disease in a client who describes intermittent claudication. A thorough assessment of the client's skin color and temperature and the character of the peripheral pulses are important in the diagnosis of arterial disorders.
Which of the following assessment results is considered a major risk factor for PAD?
BP of 160/110 mm Hg Explanation: Hypertension is considered a major risk factor for PAD. Blood pressure should be less than 130/90 mm Hg. The other laboratory results are within the recommended range of normal to high normal.
Which observation regarding ulcer formation on the client's lower extremity indicates that the ulcer is a result of venous insufficiency?
Border of the ulcer is irregular Explanation: The border of an ulcer caused by arterial insufficiency is circular. Superficial venous insufficiency ulcers cause minimal pain. The base of a venous insufficiency ulcer shows a beefy red to fibrinous yellow color. Venous insufficiency ulcers are usually superficial.
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 Explanation: Nicotine decreases blood flow, increases heart rate and blood pressure, and increases the risk for clot formation by increasing platelet aggregation. Smokers have a four-fold higher risk of developing pain from arterial disease than nonsmokers. Carbon monoxide, produced by burning tobacco, combines with hemoglobin more readily than oxygen, thus depriving tissues of oxygen.
Pentoxifylline (Trental) is a medication used for which of the following conditions?
Claudication Explanation: Trental and Pletal are the only medications specifically indicated for the treatment of claudication. Thromboemboli, hypertension, and elevated triglycerides are not indications for using Trental.
The nurse assesses a patient with hip pain related to intermittent claudication. She knows that the area of arterial narrowing is the:
Common iliac artery Explanation: The location of the claudication occurs in muscle groups distal to the diseased vessel. Hip or buttock pain may result from reduced blood flow from the common iliac artery.
The nurse is caring for a client recovering from acute axillary lymphangitis. Which treatment will the nurse anticipate being prescribed for this client after antibiotic therapy has concluded?
Compression Sleeve Explanation: Lymphangitis is an acute inflammation of the lymphatic channels. It arises most commonly from a focal area of infection in an extremity caused by bacteria. At the conclusion of antibiotic therapy used for an acute attack, a graduated compression sleeve should be worn on the affected extremity for several months to prevent long-term edema. An arm sling is not required. The client will not need aspirin therapy as there is no surgery and/or risk of clots. The client will not need physical therapy as there should be no lingering effects from treatment of lymphangitis.
A health care provider wants a cross-sectional image of the abdomen to evaluate the degree of stenosis in a patient's left common iliac artery. The nurse knows to prepare the patient for which of the following?
Computed tomography angiography (CTA) Explanation: A CTA is used to visualize arteries and veins and help assess for stenosis and occlusion.
A nurse is teaching a client who will soon be discharged with a prescription for warfarin (Coumadin). Which statement should the nurse include in discharge teaching?
Don't take aspirin while you're taking warfarin Explanation: Because aspirin decreases platelet aggregation and interferes with clotting, concomitant use of aspirin with warfarin, an anticoagulant, may lead to excessive anticoagulant effects — and bleeding. Warfarin therapy is most effective with consistent dietary intake of vitamin K. Increase intake of foods rich in vitamin K, such as broccoli, could change the client's warfarin dose requirements. Although warfarin interrupts the normal clotting cycle, it doesn't dissolve clots that have already formed. The client should take warfarin exactly as ordered to maintain the desired level of anticoagulation. Doubling a dose could cause bleeding.
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 Explanation: Homan's sign is indicated by pain in the calf after the foot is sharply dorsiflexed.
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 pallor Explanation: If arterial insufficiency is present, elevation of the limb would yield a pallor from the lack of circulation. Rubor on elevation and increased venous filling time would suggest venous problems secondary to venous trapping and incompetent valves.
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?
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?
In 3 to 5 days Explanation: Oral anticoagulants, such as warfarin, are monitored by the PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0) (Holbrook et al., 2012).
The nurse plans care for a client who is newly diagnosed with peripheral artery disease (PAD). For each nursing action, click to specify if the intervention is appropriate to increase the arterial blood supply to the client's extremities or to promote vasodilation and prevent vascular compression.
Increase: Keep legs in a dependent position, Increase in physical activity each day, Vasodilation and prevent vascular compression: Wear warm clothing in the winter, Do not use of bicotine products, Avoid crossing the legs
Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending?
Increased abdominal and back pain Explanation: Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be affected.
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?
International normalized ratio (INR) is 2.5 Explanation: Oral anticoagulants such as warfarin are monitored by PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0)
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 in your feet
A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should:
Keep the affected leg level or slightly dependent Explanation: While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg could cause accidental trauma from cuts or nicks.
The nurse is caring for a patient with peripheral arterial insufficiency. What can the nurse suggest to help relieve leg pain during rest?
Lower the limb so that it is dependent Explanation: Persistent pain in the forefoot (i.e., the anterior portion of the foot) when the patient is resting indicates a severe degree of arterial insufficiency and a critical state of ischemia. Known as rest pain, this discomfort is often worse at night and may interfere with sleep. This pain frequently requires that the extremity be lowered to a dependent position to improve perfusion to the distal tissues.
With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by:
Lowering the limb so that it is dependent Explanation: Lowering the extremity to a dependent position improves perfusion to the distal tissues.
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 Explanation: Normal people without arterial insufficiency have an ABI of about 1.0. Those with an ABI of 0.95 to 0.5 have mild to moderate arterial insufficiency. Those with an ABI of less than 0.50 have ischemic rest pain. Those with tissue loss have severe ischemia and an ABI of 0.25 or less.
Aortic dissection may be mistaken for which of the following disease processes?
Myocardial infarction (MI) Explanation: Aortic dissection may be mistaken for an acute MI, which could confuse the clinical picture and initial treatment. Aortic dissection is not mistaken for stroke, pneumothorax, or angina.
A client who is diagnosed with Raynaud syndrome reports cold and numbness in the fingers. Which finding should the nurse identify as an early sign of vasoconstriction?
Pallor Explanation: Pallor is the initial symptom in Raynaud syndrome followed by cyanosis and aching pain. Gangrene and ulceration can occur with persistent attacks and interference of blood flow.
A patient complains of a "stabbing pain and a burning sensation" in his left foot. The nurse notices that the foot is a lighter color than the rest of the skin. The artery that the nurse suspects is occluded would be the:
Posterior tibial Explanation: Clinical symptoms of PAD are manifested in organs or muscle groups supplied by specific arterial blood flow. The posterior tibial artery is a major artery that is a common site for occlusion.
A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?
Promtamine sulfate Explanation: Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn't given orally.) Thrombin is a hemostatic agent used to control local bleeding. Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it's used to treat clients who are in shock.
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?
Recent pelvic surgery Explanation: The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes mellitus is a contributing factor associated with peripheral vascular disease.
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 Explanation: Taking daily walks relieves symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may make these symptoms worse. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat, not abstain from, foods that raise HDL levels.
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 Explanation: In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the client how to apply an elastic sleeve or stocking. The nurse informs the physician if the client's temperature remains elevated. The nurse recommends elevating the area to reduce the swelling and provides warmth to promote comfort and to enhance circulation.
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?
The enoxaparin will work immediately, but the warfarin takes several days to achieve it's full effect Explanation: Oral anticoagulants such as warfarin are monitored by the prothrombin time (PT) or the international normalized ratio (INR). Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0)
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?
Venous insufficiency Explanation: Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gaiter area, and a reddish blue color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the anterior tibial area. Characteristics of arterial insufficiency ulcers include location at the tips of the toes, great pain, and circular shape with a pale to black ulcer base.
A client with a history of aching leg pain seeks medical attention for the development of a leg wound. Which assessment findings indicate to the nurse that the client is experiencing a venous ulcer? Select all that apply.
Wound is superficial, Wound has an irregular border, Thich, tough skin around the ankles, Darkened skin around the lower extremities Explanation: Aching leg pain is a symptom of venous insufficiency. Assessment findings that indicate the client is experiencing a venous ulcer include the wound is superficial with an irregular border. Thick skin around the ankles and darkened skin around the lower extremities are additional symptoms of venous insufficiency. A pale wound base is associated with an arterial ulcer.
