Test 3 Chapter 30

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.

Which term refers to enlarged, red, and tender lymph nodes? Lymphadenitis Lymphangitis Lymphedema Elephantiasis

Lymphadenitis

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 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: Internal iliac. Common femoral. Popliteal. Posterior tibial.

Posterior tibial.

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 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? Phytonadione (vitamin K) Protamine sulfate Thrombin Plasma protein fraction

Protamine sulfate

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

What should the nurse do to manage persistent swelling in a client with severe lymphangitis and lymphadenitis? Teach the client how to apply a graduated compression stocking. 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 a graduated compression stocking.

A client with venous insufficiency develops varicose veins in both legs. Which statement about varicose veins is accurate? Varicose veins are more common in men than in women. Primary varicose veins are caused by deep vein thrombosis (DVT) and inflammation. Sclerotherapy is used to cure varicose veins. The severity of discomfort isn't related to the size of varicosities.

The severity of discomfort isn't related to the size of varicosities.

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

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 scaring Cyanosis

Ulcers and infection in the edematous area

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.

As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client? Demonstrate how to self-administer IV infusions. Demonstrate how to apply and remove elastic support stockings. Assess for the sites of bleeding. Assess for skin integrity.

Demonstrate how to apply and remove elastic support stockings.

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

Ensure that the client's heels are protected and supported

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

Lymphangitis

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 teaching a client who will soon be discharged with a prescription for warfarin (Coumadin). Which statement should the nurse include in discharge teaching? "Eat more yogurt and broccoli." "This drug will dissolve any clots you may still have." "If you miss a dose, double the next dose." "Don't take aspirin while you're taking warfarin."

"Don't take aspirin while you're taking warfarin."

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."

Which of the following medications is considered a thrombolytic? Alteplase Heparin Coumadin Lovenox

Alteplase

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.

A nurse on a medical unit is caring for a client who has been diagnosed with lymphangitis. When reviewing this client's medication administration record, the nurse should anticipate which of the following? Warfarin Furosemide An antibiotic An antiplatelet aggregator

An antibiotic

The nurse explains to a patient that the primary cause of a varicose vein is: Phlebothrombosis. An incompetent venous valve. Venospasm. Venous occlusion.

An incompetent venous valve.

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.

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

Antibiotics to treat cellulitis

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

Avoid tight-fitting socks.

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

Early ambulation and leg exercises

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

Inform the health care provider that the client has signs and symptoms of VTE.

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 ratio (INR) is 2.5.

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)

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

The nurse is caring for a client 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? Risk for infection related to lymphedema Disturbed body image related to lymphedema Ineffective health maintenance related to lymphedema Risk for deficient fluid volume related to lymphedema

Risk for infection related to lymphedema

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

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

The importance of ensuring the stockings are applied evenly with no pressure points

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

Use Doppler ultrasound to identify the pulses.

The nurse is caring for a client who is known to have a high risk for venous thromboembolism. What preventive actions should the nurse recommend? Select all that apply. High-protein diet Weight loss Regular exercise Smoking cessation Calcium and vitamin D supplementation

Weight loss Regular exercise Smoking cessation

Following abdominal surgery, which factor predisposes a client to deep vein thrombosis? The client is 5' 9" tall and weighs 128 lb (58 kg). The client has been pregnant four times. The client usually walks 3 miles a day. The client will be immobile during and shortly after surgery.

The client will be immobile during and shortly after surgery.

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

"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."

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 to 2.5

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. 2.5 to 3.0 times the baseline control. 3.5 times the baseline control. 4.5 times the baseline control.

1.5 to 2.5 times the baseline control.

The nurse is monitoring a patient who is on heparin anticoagulant therapy. What should the nurse determine the therapeutic range of the international normalized ratio (INR) should be? 2.0-3.0 4.0-5.0 5.0-6.0 7.0-8.0

2.0-3.0

Beginning warfarin concomitantly with heparin can provide a stable INR by which day of heparin treatment? 5 2 3 4

5

The nurse is assessing a patient two days postoperatively who is suspected of having deep vein obstruction. The patient is complaining of pain in the left lower extremity and there is a 2-cm difference in the right and left leg circumference. What intervention can the nurse provide to promote arterial flow to the lower extremities? Administer a diuretic to decrease the edema in the left lower extremity. Assist with active range-of-motion (ROM) exercises to the left lower extremity. Apply cool compresses to the left lower extremity. Apply a heating pad to the patient's abdomen.

Apply a heating pad to the patient's abdomen.

The nurse is educating a patient with chronic venous insufficiency about prevention of complications related to the disorder. What should the nurse include in the information given to the patient? (Select all that apply.) Avoid constricting garments. Elevate the legs above the heart level for 30 minutes every 2 hours. Sit as much as possible to rest the valves in the legs. Sleep with the foot of the bed elevated about 6 inches. Sit on the side of the bed and dangle the feet.

Avoid constricting garments. Elevate the legs above the heart level for 30 minutes every 2 hours. Sleep with the foot of the bed elevated about 6 inches.

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

Causes vasospasm Reduces circulation to the extremities Impairs transport and cellular use of oxygen Increases blood viscosity

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

Deep vein thrombosis

Which class of medication lyses and dissolves thrombi? Fibrinolytic Anticoagulant Platelet inhibitors Factor XA inhibitors

Fibrinolytic

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

In 3 to 5 days

The nurse is preparing to administer warfarin to a client with deep vein thrombophlebitis (DVT). Which laboratory value would most clearly indicate that the client's warfarin is at therapeutic levels? Partial thromboplastin time (PTT) within normal reference range Prothrombin time (PT) 8 to 10 times the control International normalized ratio (INR) between 2 and 3 Hematocrit of 32%

International normalized ratio (INR) between 2 and 3

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

Lower doses of heparin are required for this client.

Which risk factor is related to venous stasis for deep vein thrombosis (DVT) and pulmonary embolism (PE)? Trauma Pacing wires Obesity Surgery

Obesity

A nurse is admitting a new client with a deep vein thrombosis in her left leg. During the admission process, which information provided by the client would be a contraindication to anticoagulant therapy? Scheduled eye surgery in 1 week A cerebral vascular bleed 10 years ago Three vaginal births, the most recent 18 months ago Diet that includes many green, leafy vegetables every day

Scheduled eye surgery in 1 week

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

Teach the client that circulatory changes during pregnancy frequently cause varicose veins.

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.

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 preventive measure for varicose veins? Sit with crossed legs for a few minutes each hour to promote relaxation. Walk for several minutes every hour to promote circulation. Elevate the legs when tired. Wear snug-fitting ankle socks to decrease edema.

Walk for several minutes every hour to promote circulation.