Ch30

A client admitted to the medical-surgical unit with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are needed. Which response by the nurse is accurate?

"The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect."

The nurse is assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse include in the education of the patient during ambulation?

"Walk to the point of pain, rest until the pain subsides, then resume ambulation."

The physician prescribed a Tegapore dressing to treat a venous ulcer. What should the nurse expect that the ankle-brachial index (ABI) will be if the circulatory status is adequate?

0.5

When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of:

1.5 to 2.5 times the baseline control.

The nurse is monitoring a patient who is on heparin anticoagulant therapy. What should the nurse determine the therapeutic range of the international normalized ratio (INR) should be?

2.0-3.0

A nursing instructor is discussing the diagnosis of intermittent claudication with students. To determine whether the students understand the pathophysiology of the disease, the instructor asks, "What percentage of the arterial lumen must be obstructed before intermittent claudication is experienced?" What answer should the students give?

50

A nurse suspects the presence of an abdominal aortic aneurysm. What assessment data would the nurse correlate with a diagnosis of abdominal aortic aneurysm? (Select all that apply.)

A pulsatile abdominal mass Low back pain Lower abdominal pain

Which of the following medications is considered a thrombolytic?

Alteplase

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

Anterior surface of the foot near the ankle joint.

A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following?

Arterial Insufficiency

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

Avoid situations that contribute to ischemic episodes.

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

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

saccular aneurysm

Collects blood in the weakened outpouching.

A health care provider wants a cross-sectional image of the abdomen to evaluate the degree of stenosis in a patient's left common iliac artery. The nurse knows to prepare the patient for which of the following?

Computed tomography angiography (CTA)

A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following?

Constant, intense back pain; falling blood pressure; and decreasing hematocrit.

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

Contrast phlebography

The most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program is that this form of exercise:

Decreased venous congestion

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

Diminished or absent pulses

Which is a characteristic of arterial insufficiency?

Dimished or absent pulses

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

Dissecting

A patient who had a colon resection 3 days ago is complaining of discomfort in the left calf. How should the nurse assess Homan's sign to determine if the patient may have a thrombus formation in the leg?

Dorsiflex the foot while the leg is elevated to check for calf pain.

A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency?

Elevate the legs periodically for at least 15-20minutes.

Assessment findings that indicate possible bleeding or recurring dissection include

Hypotension with reflex tachycardia (as evidenced by a blood pressure of 82/40 mm Hg and a heart rate of 125 beats/minute), decreased urine output, and unequal or absent peripheral pulses.

A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures?

I have my wife look at the soles of my feet each day

The nurse is caring for a patient who has started anticoagulant therapy with warfarin (Coumadin). When does the nurse understand that therapeutic benefits will begin?

In 3 to 5 days

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

Ineffective peripheral tissue perfusion related to venous congestion

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

Intermittent claudication

A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued?

International normalized ratio (INR) is 2.5.

What does cigarette smoking do

Nicotine decreases blood flow, increases heart rate and blood pressure, and increases the risk for clot formation by increasing platelet aggregation. Smokers have a four-fold higher risk of developing pain from arterial disease than nonsmokers. Carbon monoxide, produced by burning tobacco, combines with hemoglobin more readily than oxygen, thus depriving tissues of oxygen.

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

Obesity

A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities?

Participate in a regular walking program

A patient complains of a "stabbing pain and a burning sensation" in his left foot. The nurse notices that the foot is a lighter color than the rest of the skin. The artery that the nurse suspects is occluded would be the:

Posterior tibial

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

Prepare to administer protamine sulfate

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?

Protamine sulfate

A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs?

Prothrombin time (PT) - This test measures the time required for a fibrin clot to form in a citrated plasma sample following addition of calcium ions and tissue thromboplastin and compares this time with the fibrin-clotting time in a control sample. The physician should adjust anticoagulant dosages as needed, to maintain PT at 1.5 to 2.5 times the control value.

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important?

Recent pelvic surgery - The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery

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

Red, swollen skin with inflammation spreading to surrounding tissues

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

Risk factor modification

Homan's sign is indicated by pain in the calf after the foot is.

Sharply dorsiflexed

Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it's used to treat clients who are in

Shock

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

Stasis of blood Vessel wall injury Altered coagulation

A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client?

Stop smoking

What should the nurse do to manage persistent swelling in a client with severe lymphangitis and lymphadenitis?

Teach the client how to apply a graduated compression stocking

A pregnant client who developed deep vein thrombosis (DVT) in her right leg is receiving heparin I.V. on the medical floor. Physical therapy is ordered to maintain her mobility and prevent additional DVT. A nursing assistant working on the medical unit helps the client with bathing, range-of-motion exercises, and personal care. Which collaborative multidisciplinary considerations should the care plan address?

The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising.

A client with venous insufficiency develops varicose veins in both legs. Which statement about varicose veins is accurate?

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

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

The sympathetic nervous system

The nurse is assessing a hospital client who has low albumin levels due to liver disease. What assessment finding should the nurse attribute to the client's low albumin levels?

There is severe edema to the client's legs and abdomen.

Are varicose veins more common in women or men ?

They are more common in women

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

Thoracic area

primary varicose veins

Typically result from a congenital or familial predisposition that makes the vein wall less elastic

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

Ulcers and infection in the edematous area

Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as

Warfarin

Which assessment finding by the nurse is the MOST significant finding suggestive of aortic aneurysm?

abdomen bruit

The hallmark symptom of PAD in the lower extremity is intermittent claudication. This pain may be described as

aching or cramping in a muscle that occurs with the same degree of exercise or activity and is relieved with rest

Clients with varicose veins commonly complain of

aching, heaviness, itching, moderate swelling, and unsightly appearance of the legs.

A nurse is changing a dressing on an arterial suture site. The site is red, with foul-smelling drainage. Based on these symptoms, the nurse is aware to monitor for which type of aneurysm?

anastomotic

left calf circumference 1" (2.5 cm) larger than the righ

bluish urine

Which observation regarding ulcer formation on the client's lower extremity indicates that the ulcer is a result of venous insufficiency?

border of ulcer irregular

Health teaching includes advising patients on ways to reduce PAD. The nurse should always emphasize that the strongest risk factor for the development of atherosclerotic lesions is:

cigarette smoking

The nurse assesses a patient with hip pain related to intermittent claudication. She knows that the area of arterial narrowing is the:

common iliac artery

To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a 45-degree angle and then have the client sit up. The nurse suspects arterial insufficiency if the assessment reveals:

dependent pallor

Varicose veins are abnormally

dilated, tortuous, superficial veins caused by incompetent venous valves.

A patient is having an angiography to detect the presence of an aneurysm. After the contrast is administered by the interventionist, the patient begins to complain of nausea and difficulty breathing. What medication is a priority to administer at this time?

epinephrine

Which class of medication lyses and dissolves thrombi?

fibrinolytic

Thrombolytic therapy is most effective when given within

first 3 days after acute thrombosis.

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

forcing blood into the deep venous system.

Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of:

hemorrhage

A patient with diabetes is being treated for a wound on the lower extremity that has been present for 30 days. What option for treatment is available to increase diffusion of oxygen to the hypoxic wound?

hyperbaric oxygen

sclerotherapy

in which a sclerosing agent is injected into a vein, is used to treat varicose veins; it doesn't cure

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

incompetent venous valve

A nurse is developing a nursing care plan for a client with peripheral arterial disease. Which of the following will be the priority nursing diagnosis?

ineffective peripheral tissue perfusion

Vasodilation or vasoconstriction produced by an external cause will interfere with a nurse's accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should:

keep client warm

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should:

keep the affected leg slightly dependent

Which observation regarding ulcer formation on the client's lower extremity indicates to the nurse that the ulcer is a result of venous insufficiency?

large and superficial

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect:

left calf circumference 1" (2.5 cm) larger than the righ

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

lowering the limb so that it is dependent

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

may be preparing to rupture

The nurse is performing wound care for a patient with a necrotic sacral wound. The prescribed treatment is isotonic saline solution with fine mesh gauze and a dry dressing to cover. What type of debridement is the nurse performing?

nonselective debridement

secondary varicosities

occur when trauma, obstruction, DVT, or inflammation damages valves.

Anastomotic aneurysm

occurs as a result of infection at arterial suture or graft sites.

A patient complains of a "stabbing pain and a burning sensation" in his left foot. The nurse notices that the foot is a lighter color than the rest of the skin. The artery that the nurse suspects is occluded would be the:

posterior tibial

Contraindications to anticoagulant therapy include

recent or impending eye surgery, recent cerebral vascular bleeds, and recent childbirth. A diet including green leafy vegetables is not a contraindication.

A nurse is admitting a new client with a deep vein thrombosis in her left leg. During the admission process, which information provided by the client would be a contraindication to anticoagulant therapy?

scheduled eye surgery in 1 week

On a routine visit to the physician, a client with chronic arterial occlusive disease reports that he's stopped smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, which additional measure should the nurse recommend?

taking daily walks

What should the nurse do to manage the persistent swelling in a client with severe lymphangitis and lymphadenitis?

teach the client how to apply an elastic sleeve - In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the client how to apply an elastic sleeve or stocking. The nurse informs the physician if the client's temperature remains elevated. The nurse recommends elevating the area to reduce the swelling and provides warmth to promote comfort and to enhance circulation.

thrombolytic therapy is most effective when given within

the first 3 days after acute thrombosis.

In a FALSE aneurysm

the mass is actually a pulsating hematoma

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

ulceration

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

ulceration

venous ulcers

will be irregular in shape, minimal pain if superficial (can be painful), and usually located around the ankles or the anterier tibial area.