chapter 30 exam 4

A community health nurse teaches a group of older adults about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which statement?

"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."

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

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

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

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

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

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

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

0.50

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

1.5 to 2.5 times the baseline control.

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

2.0-3.0

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

3 to 5 days.

In a client with a bypass graft, the distal outflow vessel must have at least what percentage patency for the graft to remain patent?

50

A 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 diagnostic test is used to quantify venous reflux and calf muscle pump ejection?

Air plethysmography

A patient is admitted to a special critical care unit for the treatment of an arterial thrombus. The nurse is aware that the preferred drug of choice for clot removal, unless contraindicated, would be:

Alteplase.

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

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

A client in the emergency department states, "I have always taken a morning walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." Based on this statement, which priority assessment should the nurse complete?

Attempt to palpate the dorsalis pedis and posterior tibial pulses

Which of the following assessment results is considered a major risk factor for PAD?

BP of 160/110 mm Hg

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

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

Border regular and well demarcated

Pentoxifylline (Trental) is a medication used for which of the following conditions?

Claudication

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.

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 and falling blood pressure

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

Demonstrate how to apply and remove elastic support stockings.

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

Diminished or absent pulses

Which is a characteristic of arterial insufficiency?

Diminished or absent pulses

The nurse knows which diagnostic test isused to document the anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux?

Duplex ultrasound scan

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

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

Hematoma Embolization Dissection of the vessel Bleeding Stent migration

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

Hemorrhage.

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

Hyperbaric oxygen

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

Intermittent claudication

A client is diagnosed with peripheral arterial disease. Review of the client's chart shows an ankle-brachial index (ABI) on the right of 0.45. This indicates that the right foot has which of the following

Moderate to severe arterial insufficiency

Aortic dissection may be mistaken for which of the following disease processes?

Myocardial infarction (MI)

A patient with impaired renal function is scheduled for a multidetector computer tomography (MDCT) scan. What preprocedure medication may the nurse administer to this patient?

Oral N-acetylcysteine

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 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

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 nurse and physician are preparing to visit a hospitalized client with perepheral arterial disease. As you approach the client's room, the physician asks if the client has reported any intermittent claudication. The client has reported this symptom. The nurse explains to the physician which of the following details?

The client can walk about 50 feet before getting pain in the right lower leg

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

The sympathetic nervous system

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

Ulceration

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

Ulcers and infection in the edematous area

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gater area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect?

Venous insufficiency

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

ankle-brachial index

The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is

contrast phlebography.

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

keep the affected leg level or slightly dependent