Qw/exp (contains Q from PP) ch3, the pt with vascular disease

48. The client with vasospastic disorder (Raynaud's phenomenon) has coldness and numbness in the fingers. The nurse assesses the client for effects of vasoconstriction . Which of the following is an early sign of vasoconstriction? 1. Cyanosis. 2. Gangrene. 3. Pallor. 4. Rubor.

48. 3. Initially, the vasoconstriction effect produces pallor or a whitish coloring , followed by cyanosis (bluish) and finally rubor (red). Gangrene is the end result ofcomplete arterial occlusion; the skin is blackened and without a blood supply.

17. The nurse is assessing an older Caucasian male who has a history of peripheral vascular disease.The nurse observes that the man's left great toe is black. The discoloration is probably a result of: 1. Atrophy. 2. Contraction. 3. Gangrene. 4. Rubor.

17. 3. The term gangrene refers to blackened, decomposing tissue that is devoid of circulation. Chronic ischemia and death of the tissue can lead to gangrene in the affected extremity. Injury, edema, and decreased circulation lead to infection, gangrene, and tissue death. Atrophy is the shrinking of tissue, and contraction is joint stiffening secondary to disuse. The term rubor denotes a reddish color of the skin.

100. The nurse is obtaining a blood sample for a partial thromboplastin time test prescribed for a client who is taking heparin. It is 5 am when drawing the blood, the nurse should do which of the following? Select all that apply. 1. Awake the client. 2. Check the armband for client identification number and 3. Label the sample vial in front of the client. 4. Verify the room number with the room assignment. 5. Ask the client to state his/ her name.

100. 1, 2, 3, 5. When obtaining blood samples, the nurse must use two acceptable sources of identification (the client states his/ her name; the nurse verifies the client's name and identification number of the armband); verifying a room number is not acceptable as client's can be easily reassigned to other rooms. The client must be awake to state his/ her name. Blood samples must be labeled in front of the client.

29. A client is receiving pentoxifylline (Trental) for intermittent claudication. The nurse should determine the effectiveness of the drug by asking if the client: 1. Has improved circulation in the legs. 2. Can wiggle the toes. 3. Is urinating more frequently. 4. Is less dizzy.

29. 1. Although pentoxifylline's (Trental) precise mechanism of action is unknown, its therapeutic effect is to increase blood flow , and the client should have improved circulation in the legs. The client does not have nerve impairment and should be able to wiggle the toes. Urination is not improved bytaking pentoxifylline. Dizziness is a side effect of the drug, not an intended outcome.

40. The primary goal for the client with Buerger's disease is to prevent: 1. Embolus formation. 2. Fat embolus formation. . Thrombus formation. 4. Thrombophlebitis.

40. 3. Because of the inflammation, a common complication of Buerger's disease is thrombus formation and potential occlusion of the vessel. Inflammation of the immediate and small arteries and veins is involved in thedisease process. Embolus is a potential risk if a thrombus has developed. Fat embolus is associated with fractures of the bones . Thrombophlebitis occurs after thrombus formation.

88. A client is discharged after an aortic aneurysm repair with a synthetic graft to replace part of the aorta. The nurse should instruct the client to notify the physician before having: 1. Blood drawn. 2. An IV line inserted. 3. Major dental work. 4. An x-ray examination.

88. 3. The client with a synthetic graftmay need to be treated with prophylactic antibiotics before undergoing major dental work. This reduces the danger of systemic infection caused by bacteria from the oral cavity. Venous access for drawing blood, IV line insertion, and x-rays do not contribute to the risk of infection.

89. A client with deep vein thrombosis has been receiving warfarin (Coumadin) for 2 months. The client reports bleeding gums, increased bruising, and dark stools. These symptoms indicate that the medication: 1. Does not need to be changed. 2. Needs to be decreased. 3. Needs to be increased .4. Is not being taken as prescribed.

89. 2. These symptoms suggest that the client is receiving too much Coumadin . Coumadin hinders the hepatic synthesis of vitamin K- dependent clotting factors and prolongs the clotting time. Because many factors influence the effectiveness of Coumadin, the dosage is monitored closely . Signs and symptoms of blood loss include bleeding gums, petechiae, bruises, dark stools, and dark urine.

97. The nurse is assessing the pulse in a client with aortic iliac disease. On the illustration below, indicate the pulse site that will give the nurse the most useful data.

97. The nurse should assess the femoral artery. Weak or absent femoral pulses are symptomatic of aortoiliac disease.

10. The nurse is teaching a client about risk factors associated with atherosclerosis and how to reduce the risk. Which of the following is a risk factor that the client is not able to modify? 1. Diabetes. 2. Age. 3. Exercise level. 4. Dietary preferences.

10. 2. Age is a nonmodifiable risk factor for atherosclerosis. The nurse instructs the client to manage modifiable risk factors such as comorbid diseases (eg, diabetes), activity level, and diet. Controlling serum blood glucose levels, engaging in regular aerobic activity, and choosing a diet low in saturated fats can reduce the risk of developing atherosclerosis.

23. A client with peripheral vascular disease has bypass surgery. The primary goal of the plan of care after surgery is to: 1. Maintain circulation. 2. Prevent infection. 3. Relieve pain. 4. Provide education.

23. 1. Maintaining circulation in the affected extremity after surgery is the focus of care. The graft can become occluded, and the client must be assessed frequently to determine whether the graft is patent . Preventing infection and relieving pain are important but are secondary to maintaining graft patency. Education should have taken place in the preoperative phase and then continued during the recovery phase.

102. The nurse is caring for a client who has a below-the-knee amputation due to diabetic foot ulcers. The client has been somewhat confused since returning from surgery last evening but has no history of falls. The client is receiving intravenous antibiotics intermittently through a peripheral IV and has prescriptions to be up with physical therapy only. Using the Morse Fall Scale (see chart), what is this client's total score and risk level? 1. 20, low risk. 2. 30, medium risk. 3. 40, medium risk. 4. 50, high risk.

102. 4. 50, High Risk: Several variables make this client a high fall risk including secondary diagnosis of diabetes (15); intermittent IV antibiotics (20); and mental status changes (15) possibly due to anesthesia, pain, or recent limb loss. This client's assessment may clearly change as the effects of anesthesia wear off, pain is controlled, and the client becomes accustomed to ambulating with a prosthesis; because assessments may be continually changing, in most acute care facilities, a fall risk is completed every 24 hours and sometimes, every shift.

19. A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by: 1. Showing the location of the obstruction and the collateral circulation. 2. Scanning the affected extremity and identifying the areas of volume changes. 3. Using ultrasound to estimate the velocity changes in the blood vessels. 4. Determining how long the client can walk.

19. 1. An arteriogram involves injecting a radiopaque contrast agent directly into the vascular system to visualize the vessels. It usually involves computed tomographic scanning. The velocity of the blood flow can be estimated by duplex ultrasound. The client's ankle-brachial index is determined, and then the client is requested to walk. The normal response is little or no drop in anklesystolic pressure after exercise.

26. One goal in caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. To achieve this goal, the nurse should encourage the client to: 1. Avoid eating low-fat foods. 2. Elevate the legs above the heart. 3. Stop smoking. 4. Begin a jogging program.

26. 3. Nicotine causes vasospasm and impedes blood flow. Stopping smoking is the most significant lifestyle change the client can make. The client should eat low-fat foods as part of a balanced diet. The legs should not be elevated above the heart because this will impede arterial flow. The legs should be in a slightly dependent position. Jogging is not necessary and probably is not possible for many clients with arterial occlusive disease. A rehabilitation program that includes daily walking is suggested.

96. A sedentary , obese , middle-aged client is recovering from a right iliac blood clot. The nurse should develop a discharge plan with the client that will focus on participating in which of the following activities? Select all that apply. 1. Aerobic activity. 2. Strength training. 3. Weight control. 4. Stress management. 5. Wearing supportive athletic shoes.

96. 1, 3. Discharge teaching begins when the client enters the hospital. One of the risk factors for clot formation is a sedentary lifestyle, and the client should engage in daily aerobic activity , such as biking or swimming (non-weight-bearing). The client is also overweight and should plan to control the weight through dietary counseling or attending weight management programs in the community. Strength training is beneficial by increasing strength and lean body mass, but not helpful in preventing vascular disease. Stress management is not a focus based on the client's needs at this time. It is not necessary to wear special supportive shoes; comfortable shoes for walking are adequate.

1. The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation? 1. Heart rate 57 bpm. 2. SpO2 of 94% on room air. 3. Blood pressure 134/ 82. 4. Ankle-brachial index of 0.65.

1. 4. An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular disease in a client who is experiencing intermittent claudication. A Doppler ultrasound is indicated for further evaluation. The bradycardic heart rate is acceptable in an athletic client with a normal blood pressure . The SpO2 is acceptable; the client has a smoking history.

11. The nurse is assessing the lower extremities of the client with peripheral vascular disease (PVD). During the assessment, the nurse should expect to find which of the following clinical manifestations of PVD? Select all that apply. 1. Hairy legs. 2. Mottled skin. 3. Pink skin. 4. Coolness. 5. Moist skin.

11. 2, 4. Reduction of blood flow to a specific area results in decreased oxygen and nutrients. As a result , the skin may appear mottled. The skin will also be cool to the touch. Loss of hair and dry skin are other signs that the nurse may observe in a client with PVD of the lower extremities.

20. A client is scheduled to have an arteriogram . During the arteriogram, the client reports having nausea, tingling, and dyspnea. The nurse's immediate action should be to: 1. Administer epinephrine. 2. Inform the physician. 3. Administer oxygen. 4. Inform the client that the procedure is almost over.

20. 2. Clients may have an immediate or a delayed reaction to the radiopaque dye. The physician should be notified immediately because the symptoms suggest an allergic reaction. Treatment may involve administering oxygen and epinephrine. Explaining that the procedure is over does not address the current symptoms.

101. A client has acute arterial occlusion . The physician has prescribed IV heparin. Before starting the medication, the nurse should: 1. Review the blood coagulation laboratory values. 2. Test the client's stools for occult blood. 3. Count the client's apical pulse for 1 minute. 4. Check the 24-hour urine output record.

101. 1. Before starting a heparin infusion, it is essential for the nurse to know the client's baseline blood coagulation values (hematocrit, hemoglobin, and red blood cell and platelet counts). In addition, the partial thromboplastin time should be monitored closely during the process. The client's stools would be tested only if internal bleeding is suspected. Although monitoring vital signs such as apical pulse is important in assessing potential signs and symptoms of hemorrhage or potential adverse reactions to the medication, vital signs are not the most important data to collect before administering the heparin. Intake and output are not important assessments for heparin administration unless the client has fluid and volume problems or kidney disease.

84. A client has sudden, severe pain in the back and chest , accompanied by shortness of breath. The client describes the pain as a " tearing" sensation. The physician suspects the client is experiencing a dissecting aortic aneurysm. The emergency supply cart is brought into the room because one complication of a dissecting aneurysm is: 1. Cardiac tamponade. 2. Stroke. 3. Pulmonary edema. 4. Myocardial infarction.

84. 1. Cardiac tamponade is a life -threatening complication of a dissecting thoracic aneurysm. The sudden, painful "tearing" sensation is typically associated with the sudden release of blood, and the client may experience cardiac arrest. Stroke , pulmonary edema, and myocardial infarction are not common complications of a dissecting aneurysm.

93. The nurse is discharging a client with a chronic right ankle stasis ulcer. Before discharge, the nurse realizes that the client needs further teaching about wound care when the client: 1. Has made an appointment with a physical therapist. 2. Will apply a home herb mixture to the wound to promote healing. 3. Will need to be patient with the healing process. 4. Will eat a balanced diet.

93. 2. The nurse should first determinehow the client will apply an herb mixture to the ulcer. The nurse should then encourage the client to consult the physician because home remedies may be beneficial or may interfere with the medical treatment plan. In many cultures, home remedies are commonly used and may be helpful. The nurse must be sensitive to these traditions and cultural beliefs. The other statements demonstrate that the client understands the plan of care for the ulcer.

94. The nurse is caring for a client who has just had an ankle-brachial index (ABI) test. The left arm blood pressure was 160/ 80 mm Hg and a palpable systolic blood pressure of the left lower extremity was 130/ 60 mm Hg. These findings suggest that the client has: 1. Mild peripheral artery disease. 2. Moderate peripheral artery disease. 3. No apparent occlusion in the left lower extremity. 4. Severe peripheral artery disease.

94. 1. The ABI test is a noninvasive test that compares the systolic blood pressure in the arm with that of the ankle. It may be done before or after exercise. The client's highest brachial systolic pressure is divided by the left ankle systolic blood pressure to get 0.81. This score is between 0.71 and 0.90, which suggests mild peripheral artery disease. Moderate peripheral artery disease would yield a score of 0.41 to 0.70. Severe peripheral artery disease would result in a score of 0.00 to 0.40.

54. A client with vasospastic disorder (Raynaud'sphenomenon) is considering having a sympathectomy. This nurse should tell the client that the surgery is performed: 1. In the early stages of the disease to prevent further circulatory disturbances. 2. When the disease is controlled by medication. 3. When the client is unable to control stress-related vasospasm. 4. When all other treatment alternatives have failed.

54. 4. Sympathectomy is scheduled only after other treatment alternatives have been explored and have failed. Medication and stress management are beneficial strategies to prevent advancement of the disease process. If the disease is controlled by medication, there is no reason for surgery.

A client diagnosed with a deep vein thrombosis has heparin sodium infusing at 1,500 units/ h. The concentration of heparin is 25,000 units/ 500 mL. If the infusion remains at the same rate for a full 12-hour shift, how many milliliters of fluid will infuse? __________________________-mL.

71. 360 mL

22. A client who has been diagnosed with peripheral vascular disease (PVD) is being discharged. The client needs further instruction if she says she will: 1. Avoid heating pads . 2. Not cross the legs. 3. Wear leather shoes. 4. Use iodine on an injured site.

22. 4. The client should avoid using iodine or over-the-counter medications. Iodine is a highly toxic solution. An individual who has known PVD should be seen by a physician for treatment to avoid infection. The client withPVD should avoid heating pads and crossing the legs, and should wear leather shoes. A heating pad can cause injury, which, because of the decreased blood supply, can be difficult to heal. Crossing the legs can further impede blood flow. Leather shoes provide better protection.

21. A client with peripheral vascular disease has chronic, severe pretibial and ankle edema bilaterally . Because the client is on complete bed rest andcirculation is compromised, one goal is to maintain tissue integrity . Which of the following interventions will help achieve this outcome? 1. Administering pain medication. 2. Encouraging fluids. 3. Turning the client every 1 to 2 hours. 4. Maintaining hygiene.

21. 3. The client is at greater risk for skin breakdown in the lower extremities related to the edema and to remaining in one position , which increases capillary pressure. Turning the client every 1 to 2 hours promotes vasodilation and prevents vascular compression. Administering pain medication will not have an effect on skin integrity . Encouraging fluids is not a direct intervention for maintaining skin integrity, although being well hydrated is a goal for most clients. Maintaining hygiene does influence skin integrity but is secondary in this situation. CN: Physiological

12. The nurse is unable to palpate the client's left pedal pulses. Which of the following actions should the nurse take next? 1. Auscultate the pulses with a stethoscope. 2. Call the physician. 3. Use a Doppler ultrasound device. 4. Inspect the lower left extremity.

12. 3. When pedal pulses are not palpable, the nurse should obtain a Doppler ultrasound device. Auscultation is not likely to be helpful if the pulse isn't palpable . Inspection of the lower extremity can be done simultaneously when palpating, but the nurse should first try to locate a pulse by Doppler. Calling the physician may be necessary if there is a change in the client's condition.

37. The nurse is monitoring a client after an above-the-knee amputation and notes that blood has saturated through the distal part of the dressing. The nurse should immediately: 1. Apply a tourniquet. 2. Assess vital signs. 3. Call the physician. 4. Elevate the surgical extremity with a large pillow.

37. 2. The client should be evaluated for hemodynamic stability and extent of bleeding prior to calling the physician. Direct pressure can be used prior to applying a tourniquet if there is significant bleeding. To avoid flexion contractures, which can delay rehabilitation, elevation of the surgical limb is contraindicated.

64. A client is on complete bed rest. The nurse should assess the client for risk for developing which of the following complications? 1. Air embolus. 2. Fat embolus. 3. Stress fractures. 4. Thrombophlebitis.

64. 4. Thrombophlebitis is an inflammation of a vein. The underlying etiology involves stasis of blood, increased blood coagulability, and vessel wall injury . The symptoms of thrombophlebitis are pain , swelling, and deep muscle tenderness. Air embolus is a result of air entering the vascular system. Fat embolus is associated with the presence of intracellular fat globules in the lung parenchyma and peripheral circulation after long-bone fractures. Stress fractures are associated with the musculoskeletal system.

74. Which of the following clients is at risk for varicose veins? 1. A client who has had a cerebrovascular accident. 2. A client who has had anemia. 3. A client who has had thrombophlebitis. 4. A client who has had transient ischemic attacks.

74. 3. Secondary varicosities can result from previous thrombophlebitis of the deep femoral veins, with subsequent valvular incompetence. Cerebrovascular accident,anemia, and transient ischemic attacks are not associated with an increased risk of varicose veins.

9. The nurse is obtaining the pulse of a client who has had a femoral-popliteal bypass surgery 6 hours ago. (See below) Which assessment provides the most accurate information about the client's postoperative status? 1. 2.

9. 4. The presence of a strong dorsalis pedis pulse indicates that there is circulation to the extremity distal to the surgery indicating that the graft between the femoral and popliteal artery is allowing blood to circulate effectively. Answer 1 shows the nurse obtaining the radial pulse; answer 2 shows the femoral pulse, which is proximal to the surgery site and will not indicate circulation distal to the surgery site. Answer 3 shows the nurse obtaining an apical pulse.

99. The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation andimagery techniques are not relieving the client's pain and the client refuses to get out of bed to ambulate as prescribed. The nurse contacts the physician, explains the situation , and provides information about drug dose , frequency of administration, the client's vital signs, and the client's score on the pain scale. The nurse requests a prescription for a different, or stronger, pain medication. The physician tells the nurse that the current prescription for pain medication is sufficient for this client and that the client will feel better in several days. The nurse should next: 1. Explain to the physician that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed. 2. Ask the hospitalist to write a prescription for a stronger pain medication. 3. Wait until the next shift and ask the nurse on that shift to contact the physician. 4. Report the incident to the team leader.

99. 1. The nurse is the client's advocate in planning for pain relief. When presented with a communications conflict, the nurse should first restate the concern, providing as much information as needed. If the physician still does not offer an acceptable solution for pain management, the nurse can then discuss the situation with the hospitalist on the team and report the incident to the team leader. Waiting until the next shift to handle the

2. A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/ 80 to 94/ 62. What should the nurse assess first? 1. IV fluid solution .2. Pedal pulses. 3. Nasal cannula flow rate. 4. Capillary refill.

2. 2. With each set of vital signs, the nurse should assess the dorsalis pedis and posterior tibial pulses. The nurse needs to ensure adequate perfusion to the lower extremity with the drop in blood pressure. IV fluids, nasal cannula setting, and capillary refill are important to assess; however, priority is to determine the cause of drop in blood pressure and that adequate perfusion through the new graft is maintained.

49. During an initial assessment of a client diagnosed with vasospastic disorder (Raynaud's phenomenon), the nurse notes a sudden color change from pink to white in the fingers. The nurse should first assess :1. Appearance of cyanosis. 2. Radial pulse. 3. SpO2 of the affected fingers. 4. Blood pressure.

49. 2. Decreased perfusion from vasospasm induces color changes in the extremity. The degree of decreased perfusion should be assessed by taking the radial pulse. Color changes progressively to blue with cyanosis and then red when reperfusion occurs. The SpO2 requires adequate perfusion for accuracy. A blood pressure will cause further constriction and reduction of perfusion in the extremity.

13. Which of the following lipid abnormalities is a risk factor for the development of atherosclerosis and peripheral vascular disease? 1. Low concentration of triglycerides. 2. High levels of high-density lipid (HDL) cholesterol. 3. High levels of low-density lipid (LDL) cholesterol. 4. Low levels of LDL cholesterol.

13. 3. An increased LDL cholesterol concentration has been documented as a risk factor for the development of atherosclerosis. LDL cholesterol is not broken down in the liver but is deposited into the intima of the blood vessels . Low triglyceride levels are desirable. High HDL and low LDL levels are beneficial and are known to be protective for the cardiovascular system.

14. When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg? 1. Aching pain in the left calf . 2. Burning pain in the left calf. 3. Numbness and tingling in the left leg . 4. Coldness of the left foot and ankle.

14. 4. Coldness in the left foot and ankle is consistent with complete arterial obstruction. Other expected findings would includeparalysis and pallor. Aching pain, a burning sensation, or numbness and tingling are earlier signs of tissue hypoxia and ischemia and are commonly associated with incomplete obstruction. CN: Physiological

15. A client with peripheral vascular disease returns to the surgical care unit after having femoral-popliteal bypass grafting. Indicate in which order the nurse should conduct assessment of this client. 1. Postoperative pain. 2. Peripheral pulses. 3. Urine output. 4. Incision site.

15. 2. Peripheral pulses. 4. Incision site. 3. Urine output. 1. Postoperative pain. Because assessment of the presence and quality of the pedal pulses in the affected extremity is essential after surgery to make sure that the bypass graft is functioning, this step should be done first. The nurse should next ensure that the dressing is intact, and then that the client has adequate urine output. Lastly, the nurse should determine the client's level of pain.

16. A client with heart failure has bilateral + 4 edema of the right ankle that extends up to midcalf . The client is sitting in a chair with the legs in a dependent position. Which of the following goals is the priority? 1. Decrease venous congestion. 2. Maintain normal respirations. 3. Maintain body temperature. 4. Prevent injury to lower extremities.

16. 1. Decreasing venous congestion in the extremities is a desired outcome for clients with heart failure. The nurse should elevate the client's legs above the level of the heart to achieve this goal. The client is not demonstrating difficulty breathing or being cold. The nurse should prevent injury to the swollen extremity ; however , this is not the priority.

18. A client has peripheral vascular disease (PVD) of the lower extremities. The client tells the nurse, "I've really tried to manage my condition well." Which of the following routines should the nurse evaluate as having been appropriate for this client? 1. Resting with the legs elevated above the level of the heart. 2. Walking slowly but steadily for 30 minutes twice a day. 3. Minimizing activity. 4. Wearing antiembolism stockings at all times when out of bed.

18. 2. Slow, steady walking is a recommended activity for clients with peripheral vascular disease because it stimulates the development of collateral circulation. The client with PVD should not remain inactive. Elevating the legs above the heart or wearing antiembolism stockings is a strategy for alleviating venous congestion and may worsen peripheral arterial disease.

24. The nurse is instructing a client who is at risk for peripheral vascular disease how to use knee -length elastic stockings (support hose). The teaching plan should include which of the following? Select all that apply. 1. Apply the elastic stockings in the morning. 2. Remove the stockings if swelling occurs. 3. Apply the stockings while in bed. 4. Once the stockings have been pulled over the calf, roll the remaining stocking down to make a cuff. 5. Keep the stockings in place for 48 hours and reapply using a clean pair of stockings.

24. 1, 3. Elastic stockings (support hose) are used to promote circulation by preventing pooling of blood in the feet and legs. The stockings should be applied in the morning before the client gets out of bed. The stockings should be applied smoothly to avoid wrinkles, but the top should not be rolled down to avoid constriction of circulation. The stockings should be removed every 8 hours and the client should elevate the legs for 15 minutes and reapply the stockings. Clean stockings should be applied daily or as needed.

25. A client is scheduled to undergo right axillary-to-axillary artery bypass surgery. Which of the following interventions is most important for the nurse to implement in the preoperative period? 1. Assess the temperature in the affected arm. 2. Monitor the radial pulse in the affected arm. 3. Protect the extremity from cold. 4. Avoid using the arm for a venipuncture.

25. 4. If surgery is scheduled, the nurse should avoid venipunctures in the affected extremity. The goal should be to prevent unnecessary trauma and possible infection in the affected arm. Disruptions in skin integrity and even minor skin irritations can cause the surgery to be canceled. The nurse can continue to monitor the temperature and radial pulse in the affected arm; however, doing so is not the priority. Keeping the client warm is important but is not the priority at this time.

27. The client has aching, weakness, and a cramping sensation in both of the lower extremities while walking. To promote health and maintain the client's level of activity, the nurse should suggest that the client try: 1. Crosscountry skiing. 2. Jogging. 3. Golfing. 4. Riding a stationary bike.

27. 4. In this case, the exercise prescription needs to be individualized because walking causes discomfort. To maintain the level of activity and decrease venous congestion, riding a stationary bike isanother appropriate exercise behavior. Use of a stationary bike provides a non-weight -bearing exercise modality, which allows a longer duration of activity. Jogging and crosscountry skiing are weight-bearing activities. In addition, crosscountry skiing involves a cold environment, and maintaining warmth is essential in promoting arterial blood flow and preventing vasoconstriction. Golfing is a good activity, but it is not typically considered an exercise that causes aerobic changes in the body.

28. The client with peripheral vascular disease has been prescribed diltiazem (Cardizem). The nurse should determine the effectiveness of this medication by assessing the client for: 1. Relief of anxiety. 2. Sedation. 3. Vasoconstriction. 4. Vasodilation.

28. 4. Diltiazem is a calcium channel blocker that blocks the influx of calcium into the cell. In this situation, the primary use of diltiazem is to promote vasodilation and prevent spasms of the arteries. As a result of the vasodilation, blood, oxygen, and nutrients can reach the muscle and tissues. Diltiazem is not an antianxiety agent and does not promote sedation. It also does not cause vasoconstriction, which would be contraindicated for the client with peripheral vascular disease.

3. An overweight client taking warfarin (Coumadin) has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply. 1. Apply lanolin or petroleum jelly to intact skin. 2. Follow a reduced-calorie, reduced-fat diet . 3. Inspect the involved areas daily for new ulcerations . 4. Instruct the client to limit activities of daily living (ADLs). 5. Use an electric razor to shave.

3. 1, 2, 3, 5. Maintaining skin integrity is important in preventing chronic ulcers and infections. The client should be taught to inspect the skin on a daily basis. The client should reduce weight to promote circulation ; a diet lower in calories and fat is appropriate. Because the client is receiving Coumadin, the client is at risk for bleeding from cuts. To decrease the risk of cuts, the nurse should suggest that the client use an electric razor. The client with decreased arterial blood flow should be encouraged to participate in ADLs. In fact, the client should be encouraged to consult an exercise physiologist for an exercise program that enhances the aerobic capacity of the body.

30. A client with peripheral vascular disease, coronary artery disease and chronic obstructive pulmonary disease takes theophylline 200 mg twice daily every day, and digoxin 0.5 mg once a day. The physician now prescribes pentoxifylline. To prevent problematic adverse effects, the nurse should monitorthe client's: 1. Digoxin level. 2. Partial thromboplastin time (PTT). 3. Serum cholesterol level. 4. Theophylline level.

30. 4. Pentoxifylline can potentiate the effects of theophylline and increase the risk of theophylline toxicity. Therefore, the nurse should monitor the client's theophylline level. Pentoxifylline does not interact with digoxin. Pentoxifylline can interact with heparin, and the client's PTT would need to be monitored closely if the client were taking heparin. It does not affect cholesterol levels.

31. A client with a history of coronary artery disease (CAD) has been diagnosed with peripheral vascular disease. The physician started the client on pentoxifylline (Trental) once daily. Approximately 1 hour after receiving the initial dose of pentoxifylline , the client reports having chest pain. The nurse should first 1. Initiate the rapid response team. 2. Contact the physician. 3. Encourage the client to relax. 4. Document the episode in the chart.

31. 2. Angina is an adverse reaction to pentoxifylline, which should be used cautiously in clients with CAD. The nurse should report the client's symptoms to the physician, who may prescribe nitroglycerin and possibly discontinue the pentoxifylline. The client should rest until the chest pain subsides, and documentation is essential when a client experiences an adverse reaction with medications that have been prescribed ; however, the nurse's top priority is to call the physician, report the problem, and obtain a prescription for nitroglycerin. The client's reports of symptoms should never be dismissed.

32. A client with peripheral vascular disease is recovering from an aortofemoral-popliteal bypass graft. When developing a postoperative education plan, which question by the nurse will provide the most helpful information? 1. "How did you manage your health before admission?" 2. "How far could you walk without pain before surgery?" 3. "What is your home environment like?" 4. "Do you have problems with urine retention?"

32. 1. Assessing the individual's health behavior before surgery will help the nurseand client develop strategies to manage the postoperative course. Asking open-ended questions will elicit the most helpful information. The client's ability to walk after surgery will be improved after surgery. The nurse can ask direct questions after obtaining general information.

33. The client with peripheral vascular disease and a history of hypertension is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which should be the nurse's first step in planning the dietary instructions? 1. Determine the client's knowledge level about cholesterol. 2. Ask the client to name foods high in fat, cholesterol, and salt. 3. Explain the importance of complying with the diet. 4. Assess the family's food preferences.

33. 4. Before beginning dietary interventions, the nurse must assess the client's pattern of food intake, life style, food preferences, and ethnic, cultural, and financial influences.

34. While the nurse is providing preoperative teaching for a client with peripheral vascular disease who is to have a below-the-knee amputation, the client says, "I hate the idea of being an invalid after they cut off my leg." The nurse's most therapeutic response should be: 1. "You'll still have one good leg to use." 2. "Tell me more about how you're feeling." 3. "Let's finish the preoperative teaching." 4. "You're fortunate to have a wife who can take care of you."

34. 2. Encouraging the client who is undergoing amputation to verbalize feelings is the most therapeutic nursing intervention. By eliciting concerns, the nurse may be able to provide information to help the client cope. The nurse should avoid value-laden responses, such as "You'll still have one good leg," that may make the client feel guilty or hostile and block further communication. The nurse should not ignore the client's expressed concerns, nor should the nurse reinforce the client's concern about invalidism and dependency or assume that his wife is willing to care for him. CN: Psychosocial integrity;

35. The client asks the nurse, "Why can't the doctor tell me exactly how much of my leg they're going to take off? Don't you think I should know that?" The nurse responds, knowing that the final decision on the level of the amputation will depend primarily on: 1. The need to remove as much of the leg as possible. 2. The adequacy of the blood supply to the tissues. 3. The ease with which a prosthesis can be fitted. 4. The client's ability to walk with a prosthesis.

35. 2. The level of amputation commonly cannot be accurately determined until surgery, when the surgeon can directly assess the adequacy of the circulation of the residual limb. A longer residual limb facilitates prosthesis fitting and will make it easier for the client to walk. However, although these aspects will be considered in the final decision, they are not the primary factors influencing the decision. CN: Physiological

36. A client has undergone an amputation of three toes and a femoral-popliteal bypass. The nurse should teach the client that after surgery which of the following leg positions is contraindicated while sitting in a chair? 1. Crossing the legs. 2. Elevating the legs. 3. Flexing the ankles. 4. Extending the knees.

36. 1. Leg crossing is contraindicated because it causes adduction of the hips and decreases the flow of blood into the lower extremities. This may result in increased pressure in the graft in the affected leg. Elevating the legs, flexing the ankles, and extending the knees are not necessarily contraindicated.

38. The client has had a below-the-knee amputation secondary to arterial occlusive disease . The nurse is instructing the client in residual limb care. Which of the following statements by the client indicates that the client understands how to implement the plan of care? 1. "I should inspect the incision carefully when I change the dressing every other day." 2. "I should wash the incision, dry it, and apply moisturizing lotion daily." 3. "I should rewrap the stump as often as needed." 4. "I should elevate the stump on pillows to decrease swelling."

38. 3. The purpose of wrapping theresidual limb is to shape the residual limb to accept a prosthesis and bear weight. The compression bandaging should be worn at all times for many weeks after surgery and should be reapplied as needed to keep it free of wrinkles and snug. The dressing should be changed daily to allow for inspection of the stump incision. No lotions should be applied to the stump unless specifically prescribed by the physician. The stump should not be elevated on pillows because this will contribute to the formation of flexion contractures. Contractures will prevent the client from wearing a prosthesis and ambulating.

39. Which of the following clients is at greatest risk for Buerger's disease? 1. A 29 -year-old male with a 14-year history of cigarette smoking. 2. A 38-year -old female who is taking birth control pills. 3. A 54-year-old female with adult-onset diabetes. 4. A 65-year-old male with atherosclerosis.

39. 1. Thromboangiitis obliterans (Buerger's disease) is a nonatherosclerotic, inflammatory vasoocclusive disorder. The disorder occurs predominantly in younger men less than 40 years of age and there is a very strong relationship with tobacco use. Diagnosis is based on age of onset, history of tobacco use, symptoms, and exclusion of diabetes mellitus.

4. The nurse is caring for a client with peripheral artery disease who has recently been prescribed clopidogrel (Plavix). The nurse understands that more teaching is necessary when the client states which of the following: 1. "I should not be surprised if I bruise easier or if my gums bleed a little when brushing my teeth." 2. "It doesn't really matter if I take this medicine with or without food, whatever works best for my stomach." 3. "I should stop taking Plavix if it makes me feel weak and dizzy." 4. "The doctor prescribed this medicine to make my platelets less likely to stick together and help prevent clots from forming."

4. 3: Weakness, dizziness , and headache are common adverse effects of Plavix and the client should report these to the physician if they are problematic; in order to decrease risk of clot formation, Plavix must be takenregularly and should not be stopped or taken intermittently. The main adverse effect of Plavix is bleeding, which often occurs as increased bruising or bleeding when brushing teeth. Plavix is well absorbed, and while food may help decrease potential gastrointestinal upset, Plavix may be taken with or without food. Plavix is an antiplatelet agent used to prevent clot formation in clients who have experienced or are at risk for myocardial infarction, ischemic stroke, peripheral artery disease, or acute coronary syndrome.

41. A client with Buerger's disease smokes two packs of cigarettes a day. When helping a client change smoking behavior, it is important to know the client's: 1. Ability to attend support groups. 2. Goals for the treatment. 3. Perception of the negative behavior. 4. Motivation.

41. 3. When helping a client change detrimental health behavior, it is critical to learn how the client perceives the situation or problem. The client is more likely to change detrimental health behaviors if he realizes that there is a problem and that these behaviors lead to the problem. While understanding the client's ability to attend group meetings, his goals for treatment, and his motivation may help facilitate change, the nurse should first understand the client's perception of the problem and then determine what strategies might work from his perspective.

42. A client with Buerger's disease has established a goal to stop smoking. Which medication would be the most helpful in attaining this goal? 1. Bupropion . 2. Nicotine . 3. Nitroglycerin. 4. Ibuprofen.

42. 1. Bupropion is used to promote smoking cessation . All types of nicotine should be avoided to prevent vasoconstriction. Nitroglycerin, used for angina, and ibuprofen, an anti-inflammatory medication, have no role in smoking cessation.

43. The nurse is assessing a client with Buerger's disease. The nurse should determine if the client is experiencing: 1. Thickening of the intima and media of the artery. 2. Inflammation and fibrosis of arteries, veins, and nerves. 3. Vasospasm lasting several minutes. 4. Pain, pallor, and pulselessness.

43. 2. Buerger's disease is characterized by inflammation and fibrosis of arteries ,veins, and nerves. White blood cells infiltrate the area and become fibrotic , which results in occlusion of the vessels. Signs and symptoms include slowly developing claudication , cyanosis, coldness, and pain at rest . Thickening of the intima and media of the artery is characteristic of atherosclerosis. Vasospasm lasting several minutes is characteristic of Raynaud's disease. Pain, pallor, and pulselessness are symptoms of acute occlusion of an artery by an embolus or other cause (eg, compartment syndrome).

44. When instructing a client who has been newly diagnosed with vasospastic disorder (Raynaud's phenomenon) about management of care, the nurse should discuss which of the following topics? 1. Scheduling a sympathectomy procedure for the next visit. 2. Using a beta blocker medication. 3. Follow-up monitoring for development of connective tissue disease. 4. Benefit of an angioplasty to the affected extremities.

44. 3. Clients with Raynaud's phenomenon should receive routine follow-up to monitor symptoms and to assess for the development of connective tissue or autoimmune diseases associated with Raynaud's. Beta blockers are not considered first-line drug therapy. A sympathectomy is considered only in advanced cases. There is no benefit to an angioplasty , which is used for atherosclerotic vascular disease.

45. A client has been diagnosed with vasospastic disorder (Raynaud's phenomenon) on the tip of the nose and fingertips. The physician has prescribed reserpine (Serpasil ) to determine if the client will obtain relief. The client often works outside in cold weather and also smokes two packs of cigarettes per day. Which of the following should be included in the discharge plan for this client? Select all that apply. 1. Stopping smoking. 2. Wearing a face covering and gloves in thewinter. 3. Placing fingertips in cool water to rewarm them. 4. Finding employment that can be done in a warm environment. 5. Reporting signs of orthostatic hypotension.

45. 1, 2, 5. Vasospastic disorder (Raynaud's disease) is a form of intermittent arteriolar vasoconstriction that results in coldness, pain , and pallor of the fingertips , toes, or tip of the nose, and a rebound circulation with redness and pain. The nurseshould instruct the client to stop smoking because nicotine is a vasoconstrictor. An adverse effect of reserpine is orthostatic hypotension. The client should report dizziness and low blood pressure as it may be necessary to consider stopping the drug. The client should prevent vasoconstriction by covering affected parts when in cold environments. The nurse can teach the client to rewarm exposed extremities by using warm water or placing them next to the body, such as under the axilla. It is not realistic to ask this client to change jobs at this time.

46. A nurse assesses a 40-year-old female client with vasospastic disorder (Raynaud's phenomenon) involving her right hand . The nurse notes the information in the progress notes, as shown below. From these findings, the nurse should develop a plan with the client to first manage: 1. Acute pain. 2. Numbness. 3. Lack of circulation. 4. Potential for skin breakdown.

46. 2. The client has numbness in the fingertips, and the nurse should first help the client regain sensory perception and discuss strategies for prevention of injury. The client does not have acute pain. The client does have adequate circulation and is not at risk for skin breakdown at this time.

47. Which of the following clients is at greatest risk for vasospastic disorder (Raynaud's phenomenon)? 1. Young women. 2. Old women. 3. Old men. 4. Young men.

47. 1. Vasospastic disorder (Raynaud's disease) is more common in young women and is associated with collagen diseases such as rheumatoid arthritis and lupus.

5. A client is receiving Cilostazol (Pletal) for peripheral arterial disease causing intermittent claudication. The nurse determines this medication is effective when the client reports which of the following? 1. "I am having fewer aches and pains." 2. "I do not have headaches anymore." 3. "I am able to walk further without leg pain." 4. "My toes are turning grayish black in color."

5. 3. Cilostazol is indicated for management of intermittent claudication. Symptoms usually improve within 2 to 4 weeks of therapy. Intermittent claudication prevents clients from walking for long periods of time. Cilostazol inhibits platelet aggregation induced by various stimuli and improving blood flow to the muscles and allowing the client to walk long distances without pain. Peripheral arterial disease causes pain mainly of the leg muscles. "Aches and pains" does not specify exactly where the pain is occurring. Headaches may occur as a side effect of this drug, and the client should report this information to the health care provider. Peripheral arterial disease causes decreased blood supply to the peripheral tissues and may cause gangrene of the toes ; the drug is effective when the toes are warm to the touch and the color of the toes issimilar to the color of the body.

50. The nurse should instruct a client who has been diagnosed with vasospastic disorder (Raynaud's phenomenon) to: 1. Immerse the hands in cold water during an episode. 2. Wear light garments when the temperature gets below 50 ° F (10 ° C). 3. Wear gloves when handling ice or frozen foods. 4. Live in a cold climate.

50. 3. Extreme changes in temperature can precipitate a vasospastic episode and should be avoided by clients with vasospastic disorder (Raynaud's disease). The client should be encouraged to wear gloves when handling frozen foods or ice. The client should immerse the involved extremity in warm water during an episode to promote vasodilation and relaxation of the small arteries that are in spasm. The client can help prevent vasospasm brought on by temperature changes by wearing warm clothes. Living in a cold climate will exacerbate the symptoms.

51. In order to prevent recurrent vasospastic episodes with Raynaud's phenomenon, the nurse should instruct the client to: 1. Keep the hands and feet elevated as much as possible. 2. Use a vibrating massage device on the hands. 3. Wear gloves when obtaining food from the refrigerator. 4. Increase coffee intake to two cups per day.

51. 3. Loose warm clothing should be worn to protect from the cold. Wearinggloves when handling cold objects will help prevent vasospasms. Vibrating equipment and typing contribute to vasospasm. Tobacco and caffeine should be avoided. Elevation will decrease arterial perfusion during vasospasms.

52. A client with Raynaud's phenomenon is prescribed diltiazem (Cardizem). An expected outcome is: 1. Decreased heart rate. 2. Conversion to normal sinus rhythm. 3. Reduced episodes of finger numbness. 4. Increased SpO2.

52. 3. Calcium channel blockers are first-line drug therapy for the treatment of vasospasms with Raynaud's phenomenon when other therapies are ineffective. Cardizem relaxes smooth muscles and improves peripheral perfusion, therefore reducing finger numbness. Cardizem decreases heart rate and is used to treat atrial fibrillation, but these are not associated with Raynaud's. When vasospasms are prevented, an accurate SpO2 can be measured in the affected extremity; however, SpO2 is a measurement of systemic oxygenation not influenced by Cardizem.

53. When giving discharge instructions to the client with vasospastic disorder (Raynaud's phenomenon), the nurse should explain that the expected outcome of taking a beta-adrenergic blocking medication is to control the symptoms by: 1. Decreasing the influence of the sympathetic nervous system on the tissues in the hands and feet. 2. Decreasing the pain by producing analgesia. 3. Increasing the blood supply to the affected area. 4. Increasing monoamine oxidase.

53. 1. Beta-adrenergic medications block the beta-adrenergic receptors. Therefore, the expected outcome of the medication is to decrease the influence of the sympathetic nervous system on the blood vessels in the hands. Beta-adrenergic blockers have no analgesic effects . Increasing blood supply to the affected area is an indirect effect of beta-adrenergic blockers. They do not increase monoamine oxidase, which does not play arole in Raynaud's disease.

A client is being treated for deep vein thrombosis (DVT) in the left femoral artery. The physician has prescribed 60 mg of enoxaparin (Lovenox) subcutaneously. Before administering the drug, the nurse checks the client's laboratory results, noted below. Based on these results, the nurse should: 1. Assess the client for bleeding. 2. Administer the medication. 3. Inform the physician. 4. Withhold the dose of Lovenox.

55. 4. Based on the laboratory findings, prothrombin time and INR are at acceptable anticoagulation levels for the treatment of DVT. However, the platelets are below the acceptable level. Clients taking enoxaparin are at risk for thrombocytopenia. Because of the low platelet level, the nurse should withhold the enoxaparin, assess the client for bleeding, and then contact the physician.

56. A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first? 1. Elevate the head of the bed 30 to 45 degrees. 2. Encourage the client to cough and deep breathe. 3. Auscultate the lungs to detect abnormal breath sounds. 4. Contact the physician.

56. 1. Elevating the head of the bed facilitates breathing because the lungs are able to expand as the diaphragm descends. Coughing and deep breathing do not alleviate the symptoms of a pulmonary embolus, nor does lung auscultation. The physician must be kept informed of changes in a client's status, but the priority in this case is alleviating the symptoms.

acute arterial occlusion of the left lower extremity. To prevent further tissue damage , it is important for the nurse to observe for which of the following? 1. Blood pressure and heart rate changes. 2. Gradual or acute loss of sensory and motor function. 3. Metabolic acidosis. 4. Swelling in the left lower extremity.

57. 2. Acute arterial occlusion is a sudden interruption of blood flow. The interruption can be the result of complete or partial obstruction. Acute pain, loss of sensory and motor function , and a pale, mottled, numb extremity are the most dramatic and observable changes that indicate a life -threatening interruption of tissue perfusion. Blood pressure and heart rate changes may be associated with the acute pain episode. Metabolic acidosis is a complication of irreversible ischemia. Swelling may result but may also indicate venous stasis or arterial insufficiency.

58. A client with venous thrombus reports having pain in the legs. The nurse should first: 1. Elevate the foot of the bed. 2. Elevate the legs by using a pillow under the knees. 3. Encourage adequate fluid intake. 4. Massage the lower legs.

58. 1. Venous stasis can increase pain. Therefore, proper positioning in bed with the foot of the bed elevated or when sitting up in a chair can help promote venous drainage, reduce swelling, and reduce the amount of pain the client might experience. Placing a pillow under the knees causes flexion of the joint, resulting in a dependent position of the lower leg and causing a decrease in blood flow. Fluids are encouraged to maintain normal fluid and electrolyte balance but do little to relieve pain. Therapeutic massage to the legs is discouraged because of the danger of breaking up the clot.

59. A 45 -year-old client had a complete abdominal hysterectomy with bilateral salpingo-oophorectomy 2 days ago. The client's abdominal dressing is dry and intact.The client is taking liquids and voiding a sufficient quantity of straw-colored urine. While sitting up in the chair, the client has severe pain and numbness in her left leg. The nurse should first: 1. Administer pain medication. 2. Assess edema in the left leg. 3. Assess color and temperature of the left leg. 4. Encourage the client to change her position.

59. 3. The client is likely suffering from an embolus as a result of abdominal surgery . The nurse should inspect the left leg for color and temperature changes associated with tissue perfusion. Administering pain medication without gathering more information about the pain can mask important signs and symptoms. Although assessing for edema is important, it is not critical to this situation. Encouraging the client to change her position does not adequately address the need for gathering more data.

6. The client admitted with peripheral vascular disease (PVD) asks the nurse why her legs hurt whenshe walks. The nurse bases a response on the knowledge that the main characteristic of PVD is: 1. Decreased blood flow. 2. Increased blood flow. 3. Slow blood flow. 4. Thrombus formation.

6. 1. Decreased blood flow is a common characteristic of all PVD . When the demand for oxygen to the working muscles becomes greater than the supply, pain is the outcome. Slow blood flow throughout the circulatory system may suggest pump failure. Thrombus formation can result from stasis or damage to the intima of the vessels.

60. A client who is being discharged after a hospitalization for thrombophlebitis will be riding home in a car. During the 2-hour ride, the nurse should advise the client to: 1. Perform arm circles while riding in the car. 2. Perform ankle pumps and foot range-of-motion exercises. 3. Elevate the legs while riding in the car. 4. Take an ambulance home.

60. 2. Performing active ankle and foot range-of-motion exercises periodically during the ride home will promote muscular contraction and provide support to the venous system. It is the muscular action that facilitates return of the blood from the lower extremities, especially when in the dependent position. Arm circle exercises will not promote circulation in the leg. It is not necessary for the client to elevate the legs as long as the client does not occlude blood flow to the legs and does the leg exercises. It is not necessary to take an ambulance because the client is able to sit in the car safely.

61. A client is admitted with an acute onset of shortness of breath. A diagnosis of pulmonary embolism is made. One common cause of pulmonary embolism is: 1. Arteriosclerosis. 2. Aneurysm formation. 3. Deep vein thrombosis (DVT). 4. Varicose veins.

61. 3. DVT is commonly associated with venous stasis in the legs when there is a lack of the skeletal muscle pump that enhances venous return to the heart. When a client isconfined to bed rest , venous compression occurs because of the position of the lower extremities. This increased pressure causes damage to the intima lining of the veins and causes platelets to adhere to the damaged site. DVT increases the risk that a displaced plaque will become a pulmonary embolus . Arteriosclerosis is hardening of the arteries ; aneurysm is the abnormal dilation of a vessel; and varicose veins are swollen , tortuous veins. These are not generally considered causes of pulmonary embolism. CN: Physiological adaptation; CL:

62. A client with a cerebral embolus is receiving streptokinase. The nurse should evaluate the client for which of the following expected outcomes of this drug therapy? 1. Improved cerebral perfusion. 2. Decreased vascular permeability 3. Dissolved emboli. 4. Prevention of cerebral hemorrhage.

62. 3. Thrombolytic agents such as streptokinase are used for clients with a history of thrombus formation, cerebrovascular accidents, and chronic atrial fibrillation. The thrombolytic agents act by dissolving emboli. Thrombolytic agents do not directly improve perfusion or increase vascular permeability, nor do they prevent cerebral hemorrhage.

A client who weighs 187 lb (85 kg) has a prescription to receive enoxaparin (Lovenox) 1 mg/ kg. This drug is available in a concentration of 30 mg /0.3 mL. What dose would the nurse administer in milliliters? _________________ mL.

63. 0.85 mL The physician's prescription is for the client to receive enoxaparin (Lovenox) 1 mg/ kg. Therefore, the client is to receive 85 mg. The desired dose in milliliters then can be calculated by using the formula of desired dose (D) divided by dose or strength of dose on hand (H) times volume (V).

65. Knee-high sequential compression devices have been prescribed for a newly admitted client. The client reports new pain localized in the right calf area that is noted to be slightly reddened and warm to touch upon initial assessment. The nurse should first: 1. Offer analgesics as prescribed and apply the compression devices. 2. Leave the compression devices off and contact the physician to report the assessment findings. 3. Massage the area of discomfort before applying the compression devices. 4. Leave the compression devices off and report assessment findings to the oncoming shift.

65. 2. Localized pain, tenderness, redness, and warmth may be symptoms of deep vein thrombosis (DVT), information the nurse should report to the physician; the compression devices should not be applied until further evaluation is completed as intermittent compression may dislodge a thrombus. Massaging the area may dislodge a thrombus and is not recommended. The nurse may offer PRN analgesics if the client requires pain management, but the compression devices should not be applied until further evaluation is completed. Diagnosis and treatment of DVT should be discussed with the physician as soon as possible; the nurse should not wait until the next shift to report findings as a DVT can become life threatening if a thrombus travels to the lung and becomes a pulmonary embolus.

66. A client is receiving an IV infusion of 5% dextrose in water (D 5W). The skin aroundthe IV insertion site is red, warm to touch, and painful. The nurse should first: 1. Administer acetaminophen (Tylenol). 2. Change the D5W to normal saline. 3. Discontinue the IV. 4. Place a warm compress on the area.

66. 3. The first action should be to discontinue the IV. The nurse should restart the IV elsewhere and then apply a warm compress to the affected area. The nurse should administer acetaminophen or an anti -inflammatory agent only if prescribed by the physician. The type of infusion cannot be changed without a physician's prescription, and such a change would not help in this case.

67. The nurse is planning care for a client on complete bed rest. The plan of care should include all except which of the following: 1. Turning every 2 hours. 2. Passive and active range-of-motion exercises. 3. Use of thromboembolic disease (TED) support hose. 4. Maintaining the client in the supine position.

67. 4. Three factors contribute to the formation of venous thrombus and thrombophlebitis: damage to the inner lining of the vein (prolonged pressure), hypercoagulability of the blood, and venous stasis. Bed rest and immobilization are associated with decreased blood flow and venous pooling in the lower extremities. Keeping the client in the supine position would not be appropriate. Turning the client every 1 to 2 hours, passive and active range-of-motion exercises, and use of TED hose help prevent venous stasis in the lower extremities.

68. The client is admitted with left lower leg pain, a positive Homans' sign, and a temperature of 100.4 ° F (38 ° C). The nurse should assess the client further for signs of: . Aortic aneurysm. 2. Deep vein thrombosis (DVT) in the left leg. 3. IV drug abuse. 4. Intermittent claudication.

68. 2. The client demonstrates classic symptoms of DVT, and the nurse should continue to assess the client. Signs and symptoms of an aortic aneurysm includeabdominal pain and a pulsating abdominal mass. Clients with drug abuse demonstrate confusion and decreased levels of consciousness. Claudication is an intermittent pain in the leg.

69. A client is admitted with a diagnosis of thrombophlebitis and deep vein thrombosis of the right leg. A loading dose of heparin has been given in the emergency room, and IV heparin will be continued for the next several days . The nurse should develop a plan of care for this client that will involve: 1. Administering aspirin as prescribed. 2. Encouraging green leafy vegetables inthe diet. 3. Monitoring the client's prothrombin time (PT). 4. Monitoring the client's activated partial thromboplastin time (aPTT) and International Normalized Ratio (INR).

69. 4. Heparin dosage is usually determined by the physician based on the client's aPTT and INR laboratory values. Therefore, the nurse monitors these values to prevent complications. Administering aspirin when the client is on heparin is contraindicated. Green leafy vegetables are high in vitamin K and therefore are not recommended for clients receiving heparin. Monitoring of the client's PT is done when the client is receiving warfarin sodium (Coumadin).

7. The nurse is planning care for a client who is diagnosed with peripheral vascular disease (PVD) and has a history of heart failure. The nurse should develop a plan of care that is based on the fact that the client may have a low tolerance for exercise related to: 1. Decreased blood flow. 2. Increased blood flow. 3. Decreased pain. 4. Increased blood viscosity.

7. 1. A client with PVD and heart failure will experience decreased blood flow. In this situation, low exercise tolerance (oxygen demand becomes greater than the oxygen supply) may be related to less blood being ejected from the left ventricle into the systemic circulation. Decreased blood supply to the tissues results in pain. Increased blood viscosity may be a component, but it is of much less importance than the disease processes.

70. In order to prevent deep vein thrombosis (DVT) following abdominal surgery, the nurse should: 1. Restrict fluids. 2. Encourage deep breathing. 3. Assist the client to remain sedentary. 4. Use pneumatic compression stockings.

70. 4. The use of pneumatic compression stockings is an intervention used to prevent DVT. Other strategies include early ambulation, leg exercises if the client is confined to bed, adequate fluid intake, and administering anticoagulant medication as prescribed. Deep breathing would be encouraged postoperatively, but it does not prevent DVT.

72. The nurse interviews a 22-year-old female client who is scheduled for abdominal surgery the following week. The client is obese and uses estrogen-based oral contraceptives. This client is at high risk for development of: 1. Atherosclerosis. 2. Diabetes. 3. Vasospastic disorder (Raynaud's disease). 4. Thrombophlebitis.

72. 4. The data suggest an increased risk of thrombophlebitis. The risk factors in this situation include abdominal surgery, obesity, and use of estrogen-based oral contraceptives. Risk factors for atherosclerosis include genetics, older age, and a high-cholesterol diet. Risk factors for diabetes include genetics and obesity. Risk factors for vasospastic disorders include cold climate, age (16 to 40), and immunologic disorders.

73. The nurse observes that an olderfemale has small-to -moderate, distended , and tortuous veins running along the inner aspect of her lower legs. The nurse should: 1. Apply a half-leg pneumatic compression device. 2. Suggest the client contact her physician. 3. Assess the client for foot ulcers. 4. Encourage the client to avoid standing in one position for long periods of time.

73. 4. The client has varicose veins, which are evident by the tortuous, distended veins where blood has pooled. To prevent pooling of the blood, the client should not stand in one place for long periods of time. It is not necessary to use compression devices, but the client could wear support hose if she stands for long periods of time. The client can consider cosmetic surgery to remove the distended veins, but there is no indication that the client should contact the physician at this point in time. The nurse can inspect the client's feet, but the client is not at risk for ulcers at this time.

75. A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When reviewing a teaching plan with this client, the nurse determines that the client has understood the nurse's instructions when the client states a willingness to: 1. Avoid exercise . 2. Lose weight. 3. Perform leg lifts every 4 hours. 4. Wear support hose, using rubber bands to hold the stockings up.

75. 2. The client is at risk for development of varicose veins. Therefore , prevention is key in the treatment plan. Maintaining ideal body weight is the goal. In order to achieve this, the client should consume a balanced diet and participate in a regular exercise program. Depending on the individual, leg lifts may or may not be an appropriate activity. Performing leg lifts provides muscular activity and should be done more often than every 4 hours. Wearing support hose is helpful. However, the client should not use rubber bands to hold the stockings up.

76. Which instructions should the nurse include when developing a teaching plan for a client being discharged from the hospital on anticoagulant therapy after having deep vein thrombosis (DVT)? Select all that apply. 1. Checking urine for bright blood and a dark smoky color. 2. Walking daily as a good exercise. 3. Using garlic and ginger, which may decrease bleeding time. 4. Performing foot/ leg exercises and walking around the airplane cabin when on long flights. 5. Preventing DVT because of risk of pulmonary emboli. 6. Avoiding surface bumps because the skin is prone to injury.

76. 1, 2, 4, 5, 6. Clients with resolving DVT being sent home on anticoagulant therapy need instructions about assessing and preventing bleeding episodes and preventing a recurrence of DVT. Blood in the urine (hematuria) is often one of the first symptoms of anticoagulant overdose. Fresh blood in the urine is red; however, blood in the urine may also be a dark smoky color. Daily ambulation is an excellent activity to keep the venous blood circulating and thus to prevent blood clots from forming in the lower extremities. Garlic and ginger increase the bleeding time and should not be used when aclient is on anticoagulant therapy. Clients who have had previous DVTs should avoid activities that cause stagnation and pooling of venous blood. Prolonged sitting coupled with change of air pressure without foot or leg exercises or ambulation in the cabin are activities that prevent venous return. Instructing the client about prevention measures is important because clients with DVT are at high risk for pulmonary emboli (PE), which can be fatal. The client can be taught risk factors for DVT and PE. In addition, recommendations for prevention of these events also are standard protocol in practice and should be shared with the client for home care purposes . Older adults should be monitored closely for bleeding because the skin becomes thinner and the capillaries become more fragile with the aging process.

77. A client has an emergency embolectomy for an embolus in the femoral artery. After the client returns from the recovery room, in what order, from first to last, should the nurse provide care? 1. Administer pain medication. 2. Draw blood for laboratory studies. 3. Regulate the IV infusion. 4. Monitor the pulses. 5. Inspect the dressing.

77. 4. Monitor the pulses. 5. Inspect the dressing. 3. Regulate the IV infusion. 1. Administer pain medication. 2. Draw blood for laboratory studies. The nurse should first monitor the popliteal and the pedal pulses in the affected extremity after arterial embolectomy. Monitoring peripheral pulses below the site of occlusion checks the arterial circulation inthe involved extremity. The nurse should next inspect the dressing to be sure that the client is not bleeding at the surgical site. The nurse should next regulate the IV infusion to prevent fluid overload. Then the nurse should assess pain and administer pain medications as prescribed. Last, the nurse can obtain blood for laboratory studies. CN: Physiological adaptation;

The nurse is developing a discharge teaching plan for a client who underwent a repair of abdominal aortic aneurysm 4 days ago. The nurse reviews the client's chart for information about the client's history. Key findings are noted in the chart below. Based on the data and expected outcomes, which should the nurse emphasize in the teaching plan? 1. Food intake. 2. Fluid volume. 3. Skin integrity. 4. Tissue perfusion.

78. 4. The underlying pathophysiology in this client is atherosclerosis . The findings from the assessment indicate the risk factors of smoking and high blood pressure. Therefore, tissue perfusion is a priority for health promoting education . The data do not support education that focuses on food or fluid intake . Although edema is a potential problem and could contribute to poor skin integrity, the edema will likely be resolved by the aneurysm repair.

A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial assessment in the client's chart, as shown below. At 10: 30 am, the client has sharp midchest pain after having a bowel movement. What should the nurse do first? 1. Assess the client's vital signs. 2. Administer a bolus of lactated Ringer's solution. 3. Assess the client's neurologic status .4. Contact the physician.

79. 1. The size of the thoracic aneurysm is rather large, so the nurse should anticipate rupture. A sudden incidence of pain may indicate leakage or rupture. The blood pressure and heart rate will provide useful information in assessing for hypovolemic shock. The nurse needs more data before initiating other interventions. After assessment of vital signs, neurologic status , and pain, the nurse can then contact thephysician. Administering lactated Ringer's solution would require a physician's prescription.

8. When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to: 1. Competent venous valves. 2. Decreased blood volume. 3. Increase in muscular activity. 4. Increased venous pressure.

8. 4. In PVD, decreased blood flow can result in increased venous pressure. The increase in venous pressure results in an increase in capillary hydrostatic pressure, which causes a net filtration of fluid out of the capillaries into the interstitial space , resulting in edema. Valves often become incompetent with PVD. Blood volume is notdecreased in this condition. Decreased muscular action would contribute to the formation of edema in the lower extremities.

80. Nursing assessment of a 54-year-old client in the emergency department reveals severe back pain, Grey Turner's sign, nausea , blood pressure of 90/ 40, heart rate 128 bpm , and respirations 28/ min. The nurse should first: 1. Assess the urine output. 2. Place a large-bore IV 3. Position onto the left side. 4. Insert a nasogastric tube.

80. 2. The symptoms suggest an abdominal aortic aneurysm that is leaking or rupturing. An IV should be inserted for immediate volume replacement. With hypovolemia, the urine output will be diminished. Repositioning may potentiate the problem. A nasogastric tube may be considered with severe nausea and vomiting to decompress the stomach.

81. A client had a repair of a thoracoabdominal aneurysm 2 days ago. Which of the following findings should the nurse consider unexpected and report to the physician immediately? The client has: 1. Abdominal pain at 5 on a scale of 0 to 10 for the last 2 days. 2. Heart rate of 100 bpm after ambulating 200 feet (0.06 km). 3. Urine output of 2,000 mL in 24 hours. 4. Weakness and numbness in the lower extremities.

81. 4. One of the complications of a thoracoabdominal aneurysm repair is spinal cord injury. Therefore, it is important for the nurse to assess for signs and symptoms of neurologic changes at and below the site where the aneurysm was repaired. The client is expected to have moderate pain following surgery. An elevated heart rate is expected after physical exertion. It is important to monitor urine output following aneurysm surgery, but a urine output of 2,000 mL in 24 hours is adequate following surgery.

82. A client is admitted to the emergency department with severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. The primary goal at this time is to: 1. Maintain circulation. 2. Manage pain. 3. Prepare the client for emergency surgery. 4. Teach postoperative breathing exercises.

82. 3. The primary goal is to prepare the client for emergency surgery. The goal would be to prevent rupture of the aneurysm and potential death. Circulation is maintained,unless the aneurysm ruptures. When the client is prepared for surgery, the nurse should place the client in a recumbent position to promote circulation, teach the client about postoperative breathing exercises, and administer pain medication if prescribed.

83. Before surgery for a known aortic aneurysm, the client's pulse pressure beginsto widen, suggesting increased aortic valvular insufficiency. If the branches of the aortic arch are involved, the nurse should assess the client for: 1. Loss of consciousness. 2. Anxiety. 3. Headache. 4. Disorientation.

83. 1. If the aortic arch is involved, there will be a decrease in the blood flow to the cerebrum. Therefore, loss of consciousness will be observed. A sudden loss of consciousness is a primary symptom of rupture and no blood flow to the brain. Anxiety is not a sign of aortic valvular insufficiency. The end result of decreased cerebral blood flow is loss of consciousness, not headache or disorientation.

85. Which of the following increases the risk of having a large abdominal aortic aneurysm rupture? 1. Anemia. 2. Dehydration. 3. High blood pressure. 4. Hyperglycemia.

85. 3. In the preoperative phase, the goal is to prevent rupture. The client is placed in asemi-Fowler's position and in a quiet environment. The systolic blood pressure is maintained at the lowest level the client can tolerate. Anemia, dehydration, and hyperglycemia do not put the client at risk for rupture.

86. The nurse is planning care for a client who has just returned to the medical-surgical unit following repair of an aortic aneurysm . The nurse first should assess the client for: 1. Decreased urinary output. 2. Electrolyte imbalance. 3. Anxiety. 4. Wound infection.

86. 1. Following surgical repair of an aortic aneurysm , there is a potential for an alteration in renal perfusion, manifested by decreased urine output. The altered renal perfusion may be related to renal artery embolism, prolonged hypotension, or prolonged aortic crossclamping during surgery. Electrolyte imbalance and anxiety do not present imminent risk for this client ; signs of wound infection are generally not evident immediately following surgery, but the nurse should monitor the incision on an ongoing basis.

A client underwent surgery to repair an abdominal aortic aneurysm. The surgeon made an incision that extends from the xiphoid process to the pubis. At 12 noon 2 days after surgery, the client has abdominal distention. The nurse checks the progress notes in the medical record, as shown below. What is most likely contributing to the client's abdominal distention? 1. Nasogastric (NG) tube. 2. Ice chips. 3. IV fluid intake. 4. Morphine.

87. 4. The client is experiencing paralytic ileus. One of the adverse effects of morphine used to manage pain is decreased GI motility . Bowel manipulation and immobility also contribute to a postoperative ileus. Insertion of an NG tube generally prevents a postoperative ileus. The ice chips and IV fluids will not affect the ileus.

90. A well-nourished client is admitted with a stasis ulcer. The nurse assesses the ulcer and finds excavation of the skin surface as a result of sloughing of inflammatory necrotic tissue. The physician has prescribed the ulcer to be flushed with a fibrinolytic agent. Which of the following goals are appropriate for this client? Select all that apply. 1. Increase oxygen to the tissues. 2. Prevent direct trauma to the ulcer. 3. Improve nutrition. . Prevent infection. 5. Reduce pain.

90. 1, 2, 4, 5. The underlying pathophysiology in stasis ulcers of the skin surface is a result of inadequate oxygen and other nutrients to the tissues because of edema and decreased circulation. The nurse should first initiate care that will increase oxygen and improve tissue integrity. It is also important to prevent trauma to the tissues and prevent infections, which result from decreased microcirculation that limits the body's response to infection. Stasis ulcers are painful. The nurse can administer prescribedanalgesics 30 minutes before changing the dressing. There is no indication that the client's overall nutrition needs to be improved.

91. A client has had a stasis ulcer of the left ankle with 2 + pitting edema for 2 years. The client is taking chlorothiazide. The expected outcome of this drug is: 1. Improved capillary circulation. 2. Decreased blood pressure. 3. Wound healing. 4. Absence of infection.

91. 1. The result of chronic venous stasis is swelling and edema and superficial varicose veins. Diuretics will help reduce the swelling , thus improving capillary circulation. Although diuretics may decrease blood pressure, that is not the intended outcome of this drug. The nurse should teach the client to prevent infection and monitor wound healing, but these are not the primary outcomes of chlorothiazide.

92. The nurse assesses a client with a 5 × 2 stasis ulcer just above the left malleolus. The wound is open with irregular, reddened, swollen edges and there is a moderate amount of yellowish tan drainage coming from the wound. The client verbalizes pressure-type pain and rates the discomfort at 7 on a scale of 0 to 10. To maintain tissueintegrity, the primary nursing goal should focus on: 1. Administering prescribed analgesics. 2. Applying lanolin lotions to the left ankle stasis ulcer. 3. Encouraging the client to sit up in a chair four times per day. 4. Providing an over-the-bed cradle to protect the left ankle from the pressure of bed linens.

92. 4. Providing an over-the-bed cradle will decrease the amount of pressure that the linens exert upon the lower extremity and prevent further tissue breakdown. Administering prescribed analgesics would be an intervention for reducing the pain. Applying lanolin lotions to the left ankle ulcer will not promote healing . Encouraging the client to sit up in a chair four times per day is an intervention to promote activity. The nurse would elevate the involved extremity while the client is sitting up to reduce venous stasis and capillary pressure.

95. A client is admitted for a revascularization procedure for arteriosclerosis in the left iliac artery. To promote circulation in the extremities, the nurse should: 1. Position the client on a firm mattress. 2. Keep the involved extremity warm with blankets. 3. Position the left leg at or below the body's horizontal plane. 4. Encourage the client to raise and lower the leg four times every hour.

95. 3. Keeping the involved extremity at or below the body's horizontal plane will facilitate tissue perfusion and prevent tissue damage. The nurse should avoid placing the affected extremity on a hard surface, such asa firm mattress, to avoid pressure ulcers. In addition, the involved extremity should be free from heavy overlying bed linens. The nurse should handle the involved extremity in a gentle fashion to prevent friction or pressure. Raising the leg would cause occlusion to the iliac artery, which is contrary to the goal to promote arterial circulation.

98. A client with a history of hypertension and peripheral vascular disease underwent an aortobifemoral bypass graft. Preoperative medications included pentoxifylline (Trental), metoprolol (Toprol XL), and furosemide (Lasix). On postoperative day 1, the 12 noon vital signs are: Temperature 37.2 ° C; heart rate 132 bpm; respiratory rate 20; blood pressure 126/ 78. Urine output is 50 to 70 mL/ h. The hemoglobin and the hematocrit are stable . Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse recommends that the primary care provider: 1. Continues the pentoxifylline . 2. Increases the IV fluids . 3. Restarts the metoprolol. 4. Resumes the furosemide.

98. 3. The client is experiencing a rebound tachycardia from abrupt withdrawal of the beta blocker. The beta blocker should be restarted due to the tachycardia, history of hypertension, and the desire to reduce the risk of postoperative myocardial morbidity. The bypass surgery should correct the claudication and need for pentoxifylline. The furosemide and increase in fluids are not indicated since the client's urine output and blood pressure are satisfactory and there is no indication of bleeding. The potassium should also be assessed prior to starting the furosemide.