test 4 med surg 3

Which of the following are alterations noted in Virchow's triad? Select all that apply.

Stasis of blood Vessel wall injury Altered coagulation

The most important factor regulating the caliber of blood vessels, which determines resistance to flow, is:

The sympathetic nervous system.

The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack?

Avoid situations that contribute to ischemic episodes.

Which of the following is the most common site for a dissecting aneurysm?

Thoracic area Explanation: The thoracic area is the most common site for a dissecting aneurysm. About one-third of patients with thoracic aneurysms die of rupture of the aneurysm.

which term refers to leg pain that is bought on by walking and caused by arterial insufficiency

intermittent claudication

The nurse teaches the client with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes

vasospasm

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."

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 nurse is providing education about maintaining tissue integrity to a client with peripheral arterial disease. Which of the following statements by the client indicates a need for clarification?

"Shoes made of synthetic material are best for my feet."

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 its full effect."

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."

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?

0.50

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.

Which nursing diagnosis is most significant in planning the care for a client with Raynaud's disease?

Acute Pain Explanation: The hallmark symptom of Raynaud's Disease is pain related to the arterial insufficiency. Disturbed Sensory Perception associated with paresthesia can occur but is less significant than pain. Self-Care Deficit and Activity Intolerance can occur but less significant than Acute Pain.

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

When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows that therapeutic benefits will not occur for:

3 to 5 days.

You are presenting a workshop at the senior citizens center about how the changes of aging predisposes clients to vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in the older adult?

Atherosclerosis

When teaching a client with peripheral vascular disease about foot care, a nurse should include which instruction?

Avoid wearing canvas shoes. Explanation: The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, and perspiration can cause skin irritation and breakdown. Cotton and cornstarch absorb perspiration. The client should be instructed to cut toenails straight across with nail clippers.

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

5

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?

50

Approximately what percentage of the arterial lumen must be obstructed before intermittent claudication is experienced?

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?

50

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection?

Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute

A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless temporary change?

Bluish urine Explanation: Lymphangiography may turn the urine blue temporarily; it doesn't alter stool color. For several months after the procedure, the upper part of the feet may appear blue, not red. Lymphangiography doesn't affect the soles.

Which of the following medications is considered a thrombolytic?

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. Explanation: Alteplase has fewer disadvantages than the other thrombolytic agents. Refer to Table 18-2 in the text.

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 pulses.

The nurse explains to a patient that the primary cause of a varicose vein is:

An incompetent venous valve. Explanation: Varicose veins are abnormally dilated, tortuous, superficial veins caused by incompetent venous valves.

Which aneurysm occurs as a result of infection at arterial suture or graft sites?

Anastomotic

To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the:

Anterior surface of the foot near the ankle joint.

You are assessing a client recently admitted to your unit for hypotension. While assessing this client, you find a pulsatile mass near the umbilicus. What would you suspect?

Aortic aneurysm

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?

Apply a heating pad to the patient's abdomen. Explanation: Nursing interventions may involve applications of warmth to promote arterial flow and instructions to the patient to avoid exposure to cold temperatures, which causes vasoconstriction. Adequate clothing and warm temperatures protect the patient from chilling. If chilling occurs, a warm bath or drink is helpful. A hot water bottle or heating pad may be applied to the patient's abdomen, causing vasodilation throughout the lower extremities.

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

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.

Which of the following is a characteristic of an arterial ulcer?

Border regular and well demarcated

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 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

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time?

Ineffective peripheral tissue perfusion related to venous congestion

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.

Which of the following are indications of a rupturing aortic aneurysm? Select all that apply.

Constant, intense back pain Decreasing blood pressure Decreasing hematocrit

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

Which of the following is a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot?

Contrast phlebography

As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client?

Demonstrate how to apply and remove elastic support stockings.

The nurse assessing a client who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which characteristic?

Diminished or absent pulses

Which is a characteristic of arterial insufficiency?

Diminished or absent pulses

Which aneurysm results in bleeding into the layers of the arterial wall?

Dissecting

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.

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?

Epinephrine

Which statement is accurate regarding Reynaud disease?

Episodes may be triggered by unusual sensitivity to cold.

Which class of medication lyses and dissolves thrombi?

Fibrinolytic

Which of the following are complications of percutaneous transluminal balloon angioplasty (PTA)? Select all that apply.

Hematoma Embolization Dissection of the vessel Bleeding Stent migration

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

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

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.

Which is a risk factor for venous disorders of the lower extremities?

Obesity

A nurse is teaching a client newly diagnosed with arterial insufficiency. Which term should the nurse use to refer to leg pain that occurs when the client is walking?

Intermittent claudication

Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity?

Intermittent claudication

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.

A nurse assesses a patient for a possible abdominal aortic aneurysm (AAA). Which of the following signs would the nurse recognize as positive indicators? Select all that apply.

Low back pain Lower abdominal pain An abdominal pulsatile mass A systolic bruit

The nurse is caring for a patient with peripheral arterial insufficiency. What can the nurse suggest to help relieve leg pain during rest?

Lowering the limb so that it is dependent

With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by:

Lowering the limb so that it is dependent.

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.

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?

Nonselective debridement Explanation: Nonselective débridement can be accomplished by applying isotonic saline dressings of fine mesh gauze to the ulcer. When the dressing dries, it is removed (dry), along with the debris adhering to the gauze. Pain management is usually necessary.

A client with Raynaud's disease complains of cold and numbness in the fingers. Which of the following would the nurse identify as an early sign of vasoconstriction?

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?

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

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.

While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?

Prepare to administer protamine sulfate. Explanation: Frank hematuria indicates excessive anticoagulation and bleeding — and heparin overdose. The nurse should discontinue the heparin infusion immediately and prepare to administer protamine sulfate, the antidote for heparin. Decreasing the heparin infusion rate wouldn't prevent further bleeding. Although the nurse should continue to monitor PTT, this action should occur later. An I.V. infusion of D5W may be administered, but only after protamine has been given.

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?

Protamine 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 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?

Prothrombin time (PT)

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?

Raynaud's 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?

Recent pelvic surgery

When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe?

Red, swollen skin with inflammation spreading to surrounding tissues

Which of the following is the most effective intervention for preventing progression of vascular disease?

Risk factor modification Explanation: Risk factor modification is the most effective intervention for preventing progression of vascular disease. Measures to prevent tissue loss and amputation are a high priority. Patients are taught to avoid trauma; wear sturdy, well-fitting shoes or slippers; and use pH neutral soaps and body lotions.

The nurse is caring for a client with abdominal aortic aneurysm (AAA). Which assessment finding is most likely to indicate a dissection of the aneurysm?

Severe back pain

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?

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.

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

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.

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

A client with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which is the most likely cause?

The aneurysm may be preparing to rupture.

A nurse and physician are preparing to visit a hospitalized client with perepheral 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.

Following abdominal surgery, which factor predisposes a client to deep vein thrombosis?

The client will be immobile during and shortly after surgery.

The nurse is caring for a patient with venous insufficiency. What should the nurse assess the patient's lower extremities for?

Ulceration

The nurse is caring for a patient with venous insufficiency. What should the nurse assess the patient's lower extremities for?

Ulceration Explanation: Venous ulceration is the most serious complication of chronic venous insufficiency and can be associated with other conditions affecting the circulation of the lower extremities. Cellulitis or dermatitis may complicate the care of chronic venous insufficiency and venous ulcerations.

What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue?

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 gater 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

The most common site of aneurysm formation is in the:

abdominal aorta, just below the renal arteries.

A client reports pain and cramping in the thigh when climbing stairs and numbness in the legs after exertion. Which diagnostic test with the physician likely perform right in the office to determine PAD?

ankle-brachial index

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

contrast phlebography. Explanation: When a thrombus exists, an x-ray image will disclose an unfilled segment of a vein. Air plethysmography quantifies venous reflux and calf muscle pump ejection. In lymphangiography, contrast media are injected into the lymph system. In a lymphoscintigraphy, a radioactive-labeled colloid is injected into the lymph system.

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:

decreases venous congestion.

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:

forcing blood into the deep venous system.

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.

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:

left calf circumference 1" (2.5 cm) larger than the right. Explanation: Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased pulse, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT.

What symptoms should the nurse assess for in a client with lymph edema as a result of impaired nutrition to the tissue

ulcers and infection in the edematous area