Chapter 38 Vascular Disorders (Lewis)
A patient is recovering from abdominal aortic aneurysm repair. After taking the patient's vital signs, which result would necessitate immediate action by the nurse? 1 Temperature 99.9 ºF (37.7 ºC) 2 Apical pulse rate 86 beats/minute 3 Respirations rate 16 per minute 4 Blood pressure 196/100.
Avoid severe hypertension, because it may cause undue stress on the arterial anastomoses, resulting in leakage of blood or rupture at the suture lines . A low-grade temperature is normal. A heart rate of 86 is normal and not a priority. Respirations of 16 are normal. Text Reference - p. 847 4
The nurse is examining a female patient who experiences leg edema and pain. What assessment findings indicate to the nurse that the patient is at a high risk for venous thromboembolism (VTE)? Select all that apply. 1 The patient is addicted to tobacco 2 The patient has been taking oral contraceptives 3 The patient has been taking aspirin daily for one year 4 The patient has a family history of VTE 5 The patient underwent peripheral artery disease (PAD) surgery
A 36-year old woman who uses oral contraceptives and tobacco is at high risk for VTE. These compounds may cause hypercoagulability and may activate the intrinsic coagulation pathway that leads to deep vein thrombosis and pulmonary embolism. The risk increases if the patient has a family history of VTE, as the patient may carry the mutated genes responsible for the disease. PAD surgery has no direct relation to this disease, but if the endothelium is damaged during the surgery, it can initiate the coagulation cascade. Some medications, such as corticosteroids, may stimulate thrombus formation, but aspirin has shown no such tendency. Text Reference - p. 848 1,2,4,5
Assessment of a patient's peripheral intravenous (IV) site reveals that phlebitis has developed over the past several hours. Which intervention should the nurse implement first? A. Remove the patient's IV catheter B. Apply an ice pack to the affected area C. Decrease the IV rate to 20 to 30 mL/hr D. Administer prophylactic anticoagulants
A. Remove the patient's IV catheter The priority intervention for superficial phlebitis is removal of the offending IV catheter. Decreasing the IV rate is insufficient. Anticoagulants normally are not required, and warm, moist heat often is therapeutic. Text Reference - p. 847 1
A 46-year-old is diagnosed with thromboangiitis obliterans (Buerger's disease). When the nurse is planning expected outcomes for the patient, which outcome has the highest priority for this patient? a. Cessation of smoking b. Control of serum lipid levels c. Maintenance of appropriate weight d. Demonstration of meticulous foot care
ANS: A Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with Buerger's disease. Other therapies have limited success in treatment of this disease. DIF: Cognitive Level: Application REF: 881 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
A 46-year-old is diagnosed with thromboangiitis obliterans (Buerger's disease). When the nurse is developing a discharge teaching plan for the patient, which outcome has the highest priority for this patient? a. Cessation of all tobacco use b. Control of serum lipid levels c. Maintenance of appropriate weight d. Demonstration of meticulous foot care
ANS: A Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with Buerger's disease. Other therapies have limited success in treatment of this 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. have to buy some loose clothes that do not bind across my legs or waist." b. use a heating pad on my feet at night to increase the circulation and warmth in my feet." c. change my position every hour and avoid long periods of sitting with my legs crossed." d. walk to the point of pain, rest, and walk again until the pain returns for at least 30 minutes 3 times a week."
ANS: B 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.
Several hours after 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 40 mL. The nurse notifies the health care provider and anticipates an order for a(n) a. hemoglobin count. b. additional antibiotic. c. decrease in IV infusion rate. d. blood urea nitrogen (BUN) level.
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.
The nurse is monitoring a postoperative patient for venous thromboembolism (VTE). Which are probable clinical findings in a person with VTE? Select all that apply. 1 Venous distention 2 Vein appears as a palpable cord 3 Deep reddish color to the affected area 4 Itchiness and warmth over the affected area 5 Tenderness to pressure over the involved vein
Clinical findings for VTE include tenderness to pressure over involved vein, induration of overlying muscle, venous distention, edema, possible mild to moderate pain, and a deep reddish color to area caused by venous congestion. Itchiness and cord-like texture are characteristics of superficial venous thrombosis. Text Reference - p. 849 1,3,5
A patient is discharged from the hospital after undergoing femoral artery bypass surgery with synthetic graft replacement. The nurse reviews with the patient the signs and symptoms of acute arterial ischemia that occur with graft occlusion. Which is a sign of acute arterial occlusion? Select all that apply. 1 Pulse rate of 110 2 Leg is pale and white 3 Severe pain in the lower leg 4 Oral temperature of 38.2 º C 5 No hair growth on lower legs 6 Redness along the surgical incision
Clinical signs and symptoms of acute arterial ischemia are the "six Ps": pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia (leg is the temperature of the environment or cooler). A pale, white limb and severe pain are signs of acute arterial ischemia. A tachycardic heart rate of 110 and oral temperature of 38.2º C are consistent with an infection. No hair growth on legs occurs with chronic decreased circulation. A reddened incision is consistent with inflammation or infection. Text Reference - p. 838 2,3
The nurse is preparing to administer a scheduled dose of enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to administer this medication correctly? A Remove the air bubble in the prefilled syringe. B Aspirate before injection to prevent intravenous (IV) administration. C Rub the injection site after administration to enhance absorption. D Pinch the skin between the thumb and forefinger before inserting the needle.
D. The nurse should gather together or "bunch up" the skin between the thumb and the forefinger before inserting the needle into the subcutaneous tissue. The nurse should not remove the air bubble in the prefilled syringe, aspirate, or rub the site after injection. Text Reference - p. 855
The nurse would determine that the patient is not receiving the beneficial effects of enoxaparin (Lovenox) after noting which finding during a routine shift assessment? A. Generalized weakness B. Abdominal pain C. Crackles bilaterally in the lung bases D. Swelling of the right leg
D. Swelling of the right leg Enoxaparin is a low-molecular weight heparin used to prevent the development of deep-vein thromboses in the postoperative period. Homans' sign (pain in the calf on dorsiflexion of the foot) can indicate development of deep-vein thrombosis and may signal ineffective medication therapy. Generalized weakness, crackles in the lungs, and abdominal pain do not indicate lack of effectiveness of this anticoagulant. Text Reference - p. 849
The patient reports tenderness when the patient touches the leg over a vein. The nurse assesses warmth and a palpable cord in the area. The nurse knows the patient needs treatment to prevent what? A. Pulmonary embolism B. Pulmonary hypertension C. Postthrombotic syndrome D. Venous thromboembolism
D. The clinical manifestations are characteristic of a superficial vein thrombosis. If untreated, the clot may extend to deeper veins and venous thromboembolism may occur. Pulmonary embolism, pulmonary hypertension, and postthrombotic syndrome are the sequelae of venous thromboembolism. Text Reference - p. 849
A patient experiences pain in the calf while exercising and reports that the pain disappears after a few minutes of resting. The nurse recognizes the finding as most consistent with: 1 Venous obstruction in the leg 2 Claudication resulting from venous abnormalities 3 Ischemia resulting from complete blockage of an artery 4 Ischemia resulting from partial blockage of an artery
Ischemia is a deficient supply of oxygenated arterial blood to tissue. A partial blockage creates an insufficient supply, and the ischemia may be apparent only during exercise, when oxygen needs increase. Claudication does not result from venous abnormalities. Ischemic pain would not disappear with a complete blockage of an artery in the leg; the pain would be constant. Text Reference - p. 835 4
A patient is scheduled to undergo surgery for repair of an aortic dissection. Which interventions should the nurse include in the preoperative care plan? Select all that apply. 1 Providing emotional support to the patient 2 Keeping the patient in bed in a supine position 3 Monitoring changes in peripheral pulses 4 Administering opioids and sedatives as prescribed 5 Managing pain and anxiety
Many patients are anxious before surgery, and the nurse should attempt to minimize this by providing emotional and psychological support to the patient. Peripheral pulses should be observed regularly to ensure preoperative stable condition. The nurse should administer opioids and sedatives as ordered to reduce pain and restlessness. Pain and anxiety may increase the blood pressure and heart rate, which may cause the dissection to extent. Therefore, the nurse should keep the patient relaxed and free of pain. The patient should be kept in a semi-Fowler's position to maintain the lowest possible levels of heart rate (less than 60 beats/minute) and systolic BP (less than 120 mm/Hg). These vital parameters help sustain vital organ perfusion. A flat position is not suitable for these patients as this cannot help maintain perfusion. Text Reference - p. 847 1,3,4,5
A patient presents with claudication, pain in the legs and numbness of the feet. The patient is diagnosed with peripheral arterial disease (PAD). The nurse expects that what will be included in the patient's treatment plan? Select all that apply. 1 Antiplatelet therapy 2 Exercise therapy 3 Nutritional therapy 4 Sympathectomy 5 Calcium channel blockers
Peripheral arterial disease (PAD) involves thickening of the arterial walls and progressive narrowing of the lumen of the arteries. This leads to compromised circulation to the upper and lower extremities. Antiplatelet therapy with aspirin is the primary therapy to prevent risk of cardiovascular disease. Exercise therapy is useful in preventing and managing claudication. Nutritional therapy aims at maintaining a healthy weight through a well-balanced diet. Maintaining a body mass index (BMI) is less than 25 kg/m2 helps to reduce the risk factors and prevent worsening of PAD. Sympathectomy is a procedure that involves transection of a nerve, ganglion, or plexus of the sympathetic nervous system to relieve pain associated with Buerger's disease. Sustained-release calcium channel blockers are used in Raynaud's disease. Text Reference - p. 836 1,2,3
A 55-year-old man weighs 115 kg and has a history of tobacco use, high blood pressure, and a sedentary lifestyle. When developing a plan of care for this patient, the nurse recalls that the most important risk factor for peripheral artery disease (PAD) includes which of these? 1 Tobacco use 2 Excess weight 3 Sedentary lifestyle 4 High blood pressure.
Significant risk factors for PAD include tobacco use, diabetes, hyperlipidemia, elevated C-reactive protein, and uncontrolled hypertension , with the most important being tobacco use. Excess weight, sedentary lifestyle, and high blood pressure are not significant risk factors for PAD. Text Reference - p. 835 1
A nurse is providing care for a patient who is diagnosed with mild hypertension. The severity of peripheral artery disease (PAD) in the patient ranges between 0.90-0.71 and the ankle brachial index (ABI) measurement ranges between 1.00-1.40. In addition to a prescription for thiazides, what else will be included on the patient's treatment plan? Select all that apply. 1 Advising the patient to reduce dietary sodium 2 Advising the patient to exercise daily 3 Advising the patient to avoid a high cholesterol diet 4 Administering omeprazole (Prilosec) to prevent side effects of thiazides 5 Administering angiotensin converting enzyme (ACE) inhibitors
The PAD severity range and a normal ABI ratio suggest that the patient has mild symptoms of the disease. The patient can be managed with diet restrictions and lifestyle changes. The patient should reduce the intake of sodium to prevent water retention. The patient should exercise daily to keep active and prevent weight gain. A high cholesterol diet should be avoided as it can worsen hypertension. The patient can be treated with the combination of angiotensin converting enzyme (ACE) inhibitors and low doses of thiazides. These two drugs act together to treat hypertension, which is the primary cause of PAD. Omeprazole is used to treat gastroesophageal reflux disease and does not abate the side effects of thiazides. Text Reference - p. 836 1,2,3,5
A patient admitted to the health care facility with venous thromboembolism is prescribed unfractionated heparin, to be administered subcutaneously. Which interventions should the nurse follow during this procedure? Select all that apply. 1 Inject deep into abdominal fatty tissue. 2 Hold skinfold during injection. 3 Release skinfold after removing needle. 4 Avoid aspiration. 5 Rub site after injection.
When administering unfractionated heparin subcutaneously, the nurse should inject deep into the abdominal fatty tissue, hold the skinfold during injection but release before removing the needle, and avoid aspiration. The nurse should not inject intramuscularly, rub the site after injection, or aspirate. Text Reference - p. 851 1,2,4
The nurse is caring for a patient in the recovery area following a femoral-posterior tibial bypass graft. Which interventions should the nurse perform for the patient? Select all that apply. 1 Take ankle-brachial index (ABI) measurement. 2 Obtain palpable pulses. 3 Check sensation and movement. 4 Inspect operative extremity every 15 minutes. 5 Place the patient in a knee-flexed position.
When caring for the patient in the recovery area, the nurse should obtain palpable pulses, check sensation and movement of extremities, and inspect operative extremity every 15 minutes. Postoperative ABI measurements are not recommended, as they place the patient at risk for graft thrombosis. In the recovery area, the patient is not placed in a knee-flexed position; this position is adopted only during exercise 1 day postsurgery in the absence of complications. Text Reference - p. 838 2,3,4
A 67-year-old patient is admitted to the hospital with a diagnosis of venous insufficiency. Which patient statement is most supportive of the diagnosis? a. "I can't get my shoes on at the end of the day." b. "I can't seem to ever 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 (PAD).
An 80-year-old patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which actions should the nurse take first? a. Obtain the blood pressure. b. Obtain blood for laboratory testing. c. Assess for the presence of an abdominal bruit. d. Determine any family history of kidney 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 also may be done, but they will not provide information that will determine what interventions are needed immediately for this patient.
When 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 take first? a. Take the blood pressure and pulse rate. b. Check for the presence of pedal pulses. c. Assess the appearance of any ischemic ulcers. d. Start discharge teaching about antiplatelet drugs.
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 also are appropriate but can be done after determining that bleeding is not occurring. DIF: Cognitive Level: Application REF: 876-877 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which medication category will the nurse plan to include when providing patient teaching about PAD management? a. Statins b. Vitamins c. Thrombolytics d. Anticoagulants
ANS: A Current research indicates that statin use by patients with PAD improves multiple outcomes. There is no research that supports the use of the other medication categories in PAD. DIF: Cognitive Level: Application REF: 875-876 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 5. A patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. The nurse should notify the health care provider and ANS: D The patient's history and clinical manifestations are consistent with acute arterial occlusion, and rest
The health care provider prescribes an infusion of argatroban (Acova) and a. avoid giving any IM medications to prevent localized bleeding. b. discontinue the infusion for PTT values greater than 50 seconds. c. monitor posterior tibial and dorsalis pedis pulses with the Doppler. d. have vitamin K available in case reversal of the argatroban is needed.
ANS: A IM injections are avoided in patients receiving anticoagulation. A PTT of 50 seconds is within the therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by VTE. DIF: Cognitive Level: Application REF: 887 | 889-890 TOP: Nursing Process: Planning 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 physician immediately because this is an emergency situation. Because pulses are marked prior to surgery, the nurse would know whether pulses were present prior to 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.
13. The nurse has initiated discharge teaching for a patient who is to be maintained on warfarin (Coumadin) following hospitalization for venous thromboem- bolism (VTE). The nurse determines that additional teaching is needed when the patient says, a. "I should reduce the amount of green, leafy vegetables that I eat." b. "I should wear a Medic Alert bracelet stating that I take Coumadin." c. "I will need to have blood tests routinely to monitor the effects of the Coumadin." d. "I will check with my health care provider before I begin or stop any medication."
ANS: A Patients taking Coumadin 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.
A patient at the clinic says, "I have always taken an evening walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." The nurse should a. attempt to palpate the dorsalis pedis and posterior tibial pulses. b. check for the presence of tortuous veins bilaterally on the legs. c. ask about any skin color changes that occur in response to cold. d. assess for unilateral swelling, redness, and tenderness of either leg.
ANS: A 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 point to venous thromboembolism (VTE). DIF: Cognitive Level: Application REF: 878-879 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A patient who is 2 days post-femoral-popliteal bypass graft to the right leg is being cared for on the vascular unit. Which action by a licensed practical/vocational nurse (LPN/LVN) caring for the patient requires the registered nurse (RN) to intervene? a. The LPN/LVN has the patient sit in a chair for 90 minutes. b. The LPN/LVN assists the patient to walk 40 feet in the hallway. c. The LPN/LVN gives the ordered aspirin 160 mg after breakfast. d. The LPN/LVN places the patient in a Fowler's position for meals.
ANS: A The patient should avoid sitting for long periods because of the increased stress on the suture line caused by leg edema and because of the risk for venous thromboembolism (VTE). The other actions by the LPN/LVN are appropriate.
17. Which nursing action will be included in the plan of care after endovascu- lar repair of an abdominal aortic aneurysm? a. Record hourly chest tube drainage. b. Monitor fluid intake and urine output. c. Check the abdominal wound for redness or swelling. d. Teach the reason for a prolonged rehabilitation process.
ANS: B Because renal artery occlusion can occur after endovascular repair, the nurse should monitor parameters of renal function such as intake and output. Chest tubes will not be needed for endovascular surgery, the recovery period will be short, and there will not be an abdominal wound.
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. Begin oral intake. b. Obtain vital signs. c. Assess pedal pulses. d. Start discharge teaching.
ANS: B 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.
14. A 42-year-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Before discharging the patient, the nurse teaches the patient that a. sitting at the work counter, rather than standing, is recommended. b. compression stockings should be applied before getting out of bed. c. exercises such as walking or jogging cause recurrence of varicosities. d. taking one aspirin daily will help prevent clotting around venous valves.
ANS: B 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 to the patient who had just had sclerotherapy.
A patient has a 6-cm thoracic aortic aneurysm that was discovered during a 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.
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 some dyspnea d. Patient who needs teaching about the use of 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.
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. Loose, bloody stools c. Hypoactive bowel sounds d. Abdominal pain with palpation
ANS: B Loose, bloody 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.
After teaching a patient with newly diagnosed Raynaud's phenomenon about how to manage the condition, which behavior by the patient indicates that the teaching has been effective? a. The patient avoids the use of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). b. The patient exercises indoors during the winter months. c. The patient places the hands in hot water when they turn pale. d. The patient takes pseudoephedrine (Sudafed) for cold symptoms.
ANS: B 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 aspirin and NSAIDs with Raynaud's phenomenon. DIF: Cognitive Level: Application REF: 881-883 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
When developing a teaching plan for a 76-year-old patient newly diagnosed with peripheral artery disease (PAD), which instructions should the nurse include? 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.
Which actions could the nurse delegate to unlicensed assistive personnel (UAP) who are providing care for a patient who is at risk for venous thromboembolism? a. Monitor for any bleeding after anticoagulation therapy is started. b. Apply sequential compression device whenever the patient is in bed. c. Ask the patient about use of herbal medicines or dietary supplements. d. Instruct the patient to call immediately if any shortness of breath occurs.
ANS: B UAP training includes the use of equipment that requires minimal nursing judgment, such as sequential compression devices. Patient assessment and teaching require more education and critical thinking and should be done by the registered nurse (RN).
A patient tells the health care provider about experiencing cold, numb fingers when running during the winter and is diagnosed with Raynaud's phenomenon. The nurse will anticipate teaching the patient about tests for hypertension. 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, and patients should be screened for autoimmune disorders. Raynaud's phenomenon is not associated with hyperlipidemia, hypertension, or coronary artery disease.
The nurse performing an assessment with 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. a 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 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 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 accurate? a. "Administration of two anticoagulants reduces the risk for recurrent venous thrombosis." b. "Lovenox will start to dissolve the clot, and Coumadin will prevent any more clots from occurring." c. "The Lovenox will work immediately, but the Coumadin takes several days to have an effect on coagulation." d. "Because of the potential for a pulmonary embolism, it is important for you to have more than one anticoagulant."
ANS: C 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 em- bolism, and two are not necessary to reduce the risk for another VTE. DIF: Cognitive Level: Application REF: 885-888 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
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 appropriate? a. "Taking two blood thinners reduces the risk for another clot to form." b. "Lovenox will start to dissolve the clot, and Coumadin will prevent any more clots from forming." c. "Lovenox will work right away, but Coumadin takes several days to have an effect on preventing clots." 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: C 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. Furthermore, anticoagulants should not be described as blood thinners.
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 oxygen administration and notification of the health care provider. The other findings are typical of VTE.
A 23-year-old 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.
Which action by a nurse who is giving fondaparinux (Arixtra) to a patient with a lower leg venous thromboembolism (VTE) indicates that more education about the drug is needed? a. The nurse avoids rubbing the injection site after giving the drug. b. The nurse injects the drug into the abdominal subcutaneous tissue. c. The nurse ejects the air bubble in the syringe before giving the drug. d. The nurse fails to assess the partial thromboplastin time (PTT) before giving the drug.
ANS: C The air bubble is not ejected before giving fondaparinux to avoid loss of medication. The other actions by the nurse are appropriate.
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 137/88 mm Hg d. 25 mL urine output over last 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 medications can be prescribed. The other findings are typical with aortic dissection and should also be reported but do not require immediate action.
After receiving report, which patient admitted to the emergency department should the nurse assess first? a. 67-year-old who has a gangrenous left foot ulcer with a weak pedal pulse b. 58-year-old who is taking anticoagulants for atrial fibrillation and has black stools c. 50-year-old who is complaining of sudden "sharp" and "worst ever" upper back pain d. 39-year-old who has right calf tenderness, redness, and swelling after a long plane ride
ANS: C The patient's presentation is consistent with dissecting thoracic aneurysm, which will require rapid intervention. The other patients do not need urgent interventions.
When discussing risk factor modification for a 63-year-old patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus discharge 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.
Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? a. Monitor the quality and presence of the pedal pulses. b. Teach the patient the signs of possible wound infection. c. Check the lower extremities for strength and movement. d. Help the patient to use a pillow to splint while coughing.
ANS: D Assisting a patient who has already been taught how to cough is part of routine postoperative care and within the education and scope of practice for UAP. Patient teaching and assessment of essential postoperative functions such as circulation and movement should be done by RNs.
A patient is being evaluated for post-thrombotic syndrome. Which assessment will the nurse perform? a. Ask about leg pain with exercise. b. Determine the ankle-brachial index. c. Assess capillary refill in the patient's toes. d. Check for presence of lipodermatosclerosis.
ANS: D Clinical signs of post-thrombotic syndrome include lipodermatosclerosis. In this situation, the skin on the lower leg becomes scarred, and the leg becomes tapered like an "inverted bottle." The other assessments would be done for patients with peripheral arterial disease.
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. "I get short of breath when I climb a lot of stairs." c. "My fingers hurt when I go outside in cold weather." d. "My legs cramp whenever I walk more than a block."
ANS: D 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.
A 73-year-old 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 oxygen 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 leg.
The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with deep vein thrombosis. The best method for the nurse to use in elevating the patient's feet is to a place the patient in the Trendelenburg position. b. place two pillows under the calf of the affected leg. c. elevate the bed at the knee and put pillows under the feet. d. put one pillow under the thighs and two pillows 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. DIF: Cognitive Level: Application REF: 889-890 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
An abdominal x-ray report of an obese patient indicates a pulsatile mass in the periumbilical area. Further diagnostic tests confirm that the patient has an abdominal aortic aneurysm (> 6 cm). The nurse recognizes that aneurysms in the early phase are often difficult to diagnose for what reasons? Select all that apply. 1 Abdominal aortic aneurysms are often asymptomatic 2 Abdominal aortic aneurysms often go undetected by routine examinations 3 Abdominal aortic aneurysms can only be diagnosed by specialized equipment 4 Abdominal aortic aneurysms may mimic the symptoms of other diseases 5 Obesity might influence the results of abdominal x-rays
Abdominal aortic aneurysms (AAA) are often asymptomatic, and may mimic the pain associated with abdominal and back disorders. Detection of this disorder is more difficult in obese patients until the aorta becomes very large in size (>5.5 cm), as it can be hidden under thick layers of fat. The aneurysm may be identified during routine examinations of an unrelated problem. These are usually diagnosed when the patient undergoes evaluation for an unrelated problem. AAA can be easily detected through test x-rays, ultrasounds, and CT scans. Text Reference - p. 842 1,4,5
What medications should the nurse expect to include in the teaching plan for the patient to decrease the risk of cardiovascular events and death for peripheral artery disease (PAD) patients? Select all that apply. 1 Ramipril (Altace) 2 Cilostazol (Pletal) 3 Simvastatin (Zocor) 4 Clopidogrel (Plavix) 5 Warfarin (Coumadin) 6 Aspirin (acetylsalicylic acid)
Angiotensin-converting enzyme inhibitors (e.g., ramipril) are used to control hypertension. Statins (e.g., simvastatin) are used for lipid management. Aspirin is used as an antiplatelet agent. Cilostazol is used for intermittent claudication, but it does not reduce cardiovascular disease (CVD) morbidity and mortality risks. Clopidogrel may be used if the patient cannot tolerate aspirin. Anticoagulants (e.g., warfarin) are not recommended to prevent CVD events in PAD patients. Text Reference - p. 836 1,3,6
A 40-year-old man tells the nurse he has a diagnosis for the color and temperature changes of his limbs, but can't remember the name of it. He says he must stop smoking and avoid trauma and exposure of his limbs to cold temperatures to get better. This description should allow the nurse to ask the patient if he has which diagnosis? 1 Buerger's disease 2 Venous thrombosis 3 Acute arterial ischemia 4 Raynaud's phenomenon
Buerger's disease is a nonatherosclerotic, segmental, recurrent inflammatory disorder of small and medium-sized vascular vessels of the upper and lower extremities, leading to color and temperature changes of the limbs, intermittent claudication, rest pain, and ischemic ulcerations. It primarily occurs in men younger than 45 years old with a long history of tobacco or marijuana use. Buerger's disease treatment includes smoking cessation, trauma and cold temperature avoidance, and a walking program. Venous thrombosis is the formation of a thrombus in association with inflammation of the vein. Acute arterial ischemia is a sudden interruption in arterial blood flow to a tissue caused by embolism, thrombosis, or trauma. Raynaud's phenomenon is characterized by vasospasm-induced color changes of the fingers, toes, ears, and nose. Text Reference - p. 840 1
A patient presents with mild to moderate symptoms of thromboangiitis obliterans (Buerger's disease). Which intervention is most important to include on the patient's plan for treatment? 1 Administer IV iloprost 2 Prepare for diagnostic tests that will be prescribed 3 Advise complete cessation of tobacco 4 Encourage the patient to walk for 30 to 40 minutes 3 or 4 times a week.
Buerger's disease occurs most commonly in young adults who are chronic smokers. The patient has only mild to moderate symptoms of the disease. Therefore, the best way to treat is to advise the patient to quit smoking and not use any nicotine replacement products. The consumption of these products will worsen the symptoms, which may lead to a need for limb amputation. The patient can be prescribed IV iloprost to improve rest pain, promote healing of ulcerations, and decrease the need for amputation. No particular diagnostic tests are available to detect this disease. Diagnosis may be based on clinical symptoms, such as inflamed arteries, involvement of distal vessels, and presence of ischemic ulcerations. A daily walk is beneficial to reduce hypertension and prevent other cardiovascular disorders. Text Reference - p. 840 3
The postoperative patient has a prescription to receive 60 mg enoxaparin (Lovenox). Which injection site should the nurse use to administer this medication safely? 1 Abdomen 2 Thigh 3 Deltoid 4 Flank
Enoxaparin is a low-molecular-weight heparin that is given as a subcutaneous injection. The preferred injection sites for this medication are the right and left anterolateral abdominal wall. All subcutaneous injections should be given away from scars, lesions, or moles. The thigh and flank are not appropriate sites for administering enoxaparin because of poorer absorption of the medication in the thigh or flank, and it should not be given intramuscularly in the deltoid because of risk of hematoma development. Text Reference - p. 851 1
The nurse is teaching a patient who has been newly diagnosed with Raynaud's phenomenon to avoid potential triggers, which include which of these? Select all that apply. 1 Wearing gloves 2 Drinking coffee 3 Exposure to heat 4 Emotional upsets 5 Cigarette smoking
Exposure to cold (not heat), emotional upsets, tobacco use, and caffeine often bring on symptoms of Raynaud's phenomenon. Wearing gloves often is recommended to protect the hands from exposure to cold. Text Reference - p. 841 2,4,5
A patient is diagnosed with chronic venous insufficiency (CVI). When developing the plan of treatment, in which order should the nurse perform interventions to provide the most effective care to the patient? 1. Choose an appropriate compression therapy 2. Evaluate the efficiency of interventions on a regular basis 3. Teach the patient about the significance of a balanced diet 4. Assess the patient to determine the severity level of the disease
The nurse should assess the patient before determining any treatment plan. Most patients suffering with CVI can be treated by conventional methods. These methods include applying moisturizer to prevent itching and cracking of the skin, and starting a balanced diet that includes proteins, carbohydrates, vitamins, and micronutrients to boost immunity and improve the healing process. In more severe cases, compression therapy can be started; however, each patient should be evaluated before the nurse determines the type of therapy. If the patient has peripheral arterial disease, a high level of compression should not be used, as it may induce extra pressure on arteries. This therapy is used to heal venous ulcers and to prevent recurrence. Routine evaluations are desirable to check the efficiency of the therapy. Text Reference - p. 858 1,3,2,4
A diabetic patient is being discharged after distal peripheral bypass surgery below the knee. Which instructions should the nurse include when talking to the patient and caregiver before discharge? Select all that apply. 1 Encourage supervised exercise training. 2 Teach the importance of foot care. 3 Instruct the patient to stand and relax for several minutes between walks. 4 Instruct the patient to visit a podiatrist if required. 5 Ask the patient to wear pointed shoes with soft insoles.
The nurse should encourage supervised exercise training to improve a number of cardiovascular disease risk factors, including hypertension, hyperlipidemia, obesity, and glucose levels. Meticulous foot care is important to prevent infection, especially in a diabetic patient. Thick or overgrown toenails and calluses are potentially serious and require regular attention by a podiatrist. The patient should take several short walks a day and rest between activities but avoid prolonged standing. The patient should be encouraged to wear comfortable shoes with rounded toes and soft insoles. Text Reference - p. 839 1,2,4
The nurse is reviewing discharge instructions with a patient who is taking warfarin (Coumadin) as treatment for venous thromboembolism (VTE). Which substances will the patient need to avoid while taking warfarin? Select all that apply. 1 Aspirin 2 Gingko biloba 3 Fish oil supplements 4 Acetaminophen (Tylenol) 5 Foods containing vitamin K
The patient on oral anticoagulants needs to be taught to avoid taking aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), fish oil supplements, garlic supplements, ginkgo biloba, and certain antibiotics. Acetaminophen can be taken with oral anticoagulants. Foods containing vitamin K can be eaten as long as the intake of these foods is consistent. Text Reference - p. 854 1,2,3
The nurse is reviewing the laboratory test results for a patient whose warfarin (Coumadin) therapy was terminated during the preoperative period. The nurse concludes that the patient is in the most stable condition for surgery after noting which international normalized ratio (INR) results? 1 1 2 1.8 3 2.7 4 3.4
The therapeutic range for INR is 2.0 to 3.0 for many clinical diagnoses. The larger the number, the greater the amount of anticoagulation. For this reason, the safest value before surgery is 1.0, meaning that the anticoagulation has been reversed. 1.8, 2.7, and 3.4 are higher values, indicating an increased risk of bleeding. Text Reference - p. 852 1
After assessing a patient, the nurse identifies that the patient is in the initial stage of Raynaud's disorder. Which symptom most likely supports the nurse's observation? 1 Throbbing, tingling, and swelling of the limbs 2 Chronic ischemic pain and ulcers on both feet 3 Hypertension, hyperglycemia, and inflamed arteries 4 Color changes of fingers and toes from white to blue to red
The vasospasm-induced color changes (from white to blue to red) of fingers, toes, ears, and nose are the phenomenal characteristics of Raynaud's disorder. Decreased perfusion leads to pallor (white), followed by cyanotic (bluish purple) digits that further turn red when blood flow is restored. In the later phases of the disease, the patient may complain about numbness and coldness along with throbbing, tingling, and swelling. Chronic ischemic pain and ulceration may indicate peripheral artery disease, whereas hypertension, hyperglycemia, and inflamed arteries may indicate one or more cardiovascular disorders. Further diagnostic tests are desirable to confirm the disease. Text Reference - p. 840 4
A female patient with critical limb ischemia has had peripheral artery bypass surgery to improve her circulation. What care should the nurse provide on postoperative day 1? 1 Keep the patient on bed rest 2 Assist the patient with walking several times 3 Have the patient sit in the chair several times 4 Place the patient on her side with knees flexed
To avoid blockage of the graft or stent, the patient should walk several times on postoperative day 1 and subsequent days. Having the patient's knees flexed for sitting in a chair or in bed increase the risk of venous thrombosis and may place stress on the suture lines. Text Reference - p. 836 2
The nurse is admitting a 68-year-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication? 1 Vitamin K 2 Cobalamin 3 Heparin sodium 4 Protamine sulfate
Warfarin is a vitamin K antagonist anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin. Protamine sulfate is the antidote for heparin sodium and cobalamin is vitamin B12. Heparin sodium is not the antidote for warfarin. Text Reference - p. 850 1
