Chapter 37 Vascular Disorders (Lewis)

1. When assessing a patient with possible peripheral artery disease (PAD), the nurse obtains a brachial BP of 147/82 and an ankle pressure of 112/74. The nurse calculates the patient's ankle-brachial index (ABI) as ________ (round up to the nearest hundredth).

ANSWER: 112/147=0.76 0.76 (The ABI is calculated by dividing the ankle systolic BP by the brachial systolic BP)

16. A 67-year-old patient is admitted to the hospital with a diagnosis of venous insufficiency. Which patient statement is most supportive of the diagnosis?

a. "I can't get my shoes on at the end of the day." (Because the edema associated with venous insufficiency increases when the patient has been standing, shoes will feel tighter at the end of the day.)

28. A 46-year-old is diagnosed with thromboangiitis obliterans (Buerger's disease). When the nurse is developing a discharge teaching plan for the patient, which outcome has the highest priority for this patient?

a. Cessation of all tobacco use (Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with Buerger's disease. Other therapies have limited success in treatment of this disease.)

24. The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first?

a. Notify the surgeon and anesthesiologist. (Lower extremity pulses may be absent for a short time after surgery because of vasospasm and hypothermia. Decreased or absent pulses together with a cool and mottled extremity may indicate embolization or graft occlusion. These findings should be reported to the physician immediately because this is an emergency situation.)

22. An 80-year-old patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which actions should the nurse take first?

a. Obtain the blood pressure. (Because the patient appears to be experiencing aortic dissection, the nurse's first action should be to determine the hemodynamic status by assessing blood pressure. The other actions also may be done, but they will not provide information that will determine what interventions are needed immediately for this patient.)

4. A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which group of medications will the nurse plan to include when providing patient teaching about PAD management?

a. Statins (Current research indicates that statin use by patients with PAD improves multiple outcomes.)

27. A patient who is 2 days post-femoral-popliteal bypass graft to the right leg is being cared for on the vascular unit. Which action by a licensed practical/vocational nurse (LPN/LVN) caring for the patient requires the registered nurse (RN) to intervene?

a. The LPN/LVN has the patient sit in a chair for 90 minutes. (The patient should avoid sitting for long periods because of the increased stress on the suture line caused by leg edema and because of the risk for venous thromboembolism [VTE]. The other actions by the LPN/LVN are appropriate.)

9. After teaching a patient with newly diagnosed Raynaud's phenomenon about how to manage the condition, which action by the patient demonstrates that the teaching has been effective?

a. The patient exercises indoors during the winter months. (Patients should avoid temperature extremes by exercising indoors when it is cold. To avoid burn injuries, the patient should use warm, rather than hot, water to warm the hands. Pseudoephedrine is a vasoconstrictor, and should be avoided. There is no reason to avoid taking NSAIDs with Raynaud's phenomenon.)

13. The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) following hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says which of the following?

b. "I should reduce the amount of green, leafy vegetables that I eat." (Patients taking warfarin are taught to follow a consistent diet with regard to foods that are high in vitamin K, such as green, leafy vegetables.)

21. When developing a teaching plan for a 76-year-old patient newly diagnosed with peripheral artery disease (PAD), which instructions should the nurse include?

b. "It is very important that you stop smoking cigarettes." (Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death.)

33. Which actions could the nurse delegate to unlicensed assistive personnel (UAP) who are providing care for a patient who is at risk for venous thromboembolism?

b. Apply sequential compression device whenever the patient is in bed. (UAP training includes the use of equipment that requires minimal nursing judgment, such as sequential compression devices. Patient assessment and teaching require more education and critical thinking and should be done by the registered nurse)

25. When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider?

b. Loose, bloody stools (Loose, bloody stools at this time may indicate intestinal ischemia or infarction, and should be reported immediately because the patient may need an emergency bowel resection.)

17. Which nursing action should be included in the plan of care after endovascular repair of an abdominal aortic aneurysm?

b. Monitor fluid intake and urine output. (Because renal artery occlusion can occur after endovascular repair, the nurse should monitor parameters of renal function such as intake and output.)

26. The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action should the nurse perform first?

b. Obtain vital signs. (Bleeding is a possible complication after catheterization of the femoral artery, so the nurse's first action should be to assess for changes in vital signs that might indicate hemorrhage. The other actions are also appropriate but can be done after determining that bleeding is not occurring.)

34. The nurse who works in the vascular clinic has several patients with venous insufficiency scheduled today. Which patient should the nurse assign to an experienced licensed practical/vocational nurse (LPN/LVN)?

b. Patient who needs wound care for a chronic venous stasis ulcer on the right lower leg (LPN education and scope of practice includes wound care. The other patients, which require more complex assessments or education, should be managed by the RN.)

11. The health care provider prescribes an infusion of heparin (Hep-Lock) and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). The nurse will plan to

b. avoid giving any IM medications to prevent localized bleeding. (IM injections are avoided in patients receiving anticoagulation. A PTT of 65 seconds is within the therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by VTE.)

2. A patient has a 6-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining an admission history from the patient, it will be most important for the nurse to ask about

b. trouble swallowing (Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the esophagus.)

8. When evaluating the discharge teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says, "I will

b. use a heating pad on my feet at night to increase the circulation and warmth in my feet." (Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns.)

18. Which action by a nurse who is giving fondaparinux (Arixtra) to a patient with a lower leg venous thromboembolism (VTE) indicates that more education about the drug is needed?

c. The nurse ejects the air bubble in the syringe before giving the drug. (The air bubble is NOT ejected before giving fondaparinux to avoid loss of medication.)

12. A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is most appropriate?

c. "Lovenox will work right away, but Coumadin takes several days to have an effect on preventing clots." (Low molecular weight heparin [LMWH] is used because of the immediate effect on coagulation and discontinued once the international normalized ratio [INR] value indicates that the warfarin has reached a therapeutic level. LMWH has no thrombolytic properties.)

23. After receiving report, which patient admitted to the emergency department should the nurse assess first?

c. 50-year-old who is complaining of sudden "sharp" and "worst ever" upper back pain (The patient's presentation is consistent with dissecting thoracic aneurysm, which will require rapid intervention. The other patients do not need urgent interventions.)

31. The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider?

c. Blood pressure 137/88 mm Hg (The blood pressure is typically kept at less than 120 mm Hg systolic to minimize extension of the dissection. The nurse will need to notify the health care provider so that b-blockers or other antihypertensive medications can be prescribed.)

14. A 46-year-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Which instructions should the nurse provide to the patient before discharge?

c. Elastic compression stockings should be applied before getting out of bed. (Elastic compression stockings are applied with the legs elevated to reduce pressure in the lower legs. Walking is recommended to prevent recurrent varicosities.)

29. Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse?

c. New onset shortness of breath (New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as oxygen administration and notification of the health care provider. The other findings are typical of VTE.)

19. A 23-year-old patient tells the health care provider about experiencing cold, numb fingers when running during the winter and Raynaud's phenomenon is suspected. The nurse will anticipate teaching the patient about tests for

c. autoimmune disorders. (Secondary Raynaud's phenomenon may occur in conjunction with autoimmune diseases such as rheumatoid arthritis. Patients should be screened for autoimmune disorders. Raynaud's phenomenon is NOT associated with hyperlipidemia, hyperglycemia, or coronary artery disease.)

7. The nurse performing an assessment with a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe would expect to find

c. prolonged capillary refill in all the toes. (Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery.)

20. While working in the outpatient clinic, the nurse notes that a patient has a history of intermittent claudication. Which statement by the patient would support this information?

d. "My legs cramp whenever I walk more than a block." (Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication.)

15. Which topic should the nurse include in patient teaching for a patient with a venous stasis ulcer on the left lower leg?

d. Application of elastic compression stockings (Compression of the leg is essential to healing of venous stasis ulcers. High dietary intake of protein, rather than carbohydrates, is needed. Moist dressings are used to hasten wound healing.)

32. A patient is being evaluated for post-thrombotic syndrome. Which assessment will the nurse perform?

d. Check for presence of lipodermatosclerosis. (Clinical signs of post-thrombotic syndrome include lipodermatosclerosis. In this situation, the skin on the lower leg becomes scarred, and the leg becomes tapered like an "inverted bottle." The other assessments would be done for patients with peripheral arterial disease.)

35. The nurse reviews the admission orders shown in the accompanying figure for a patient newly diagnosed with peripheral artery disease. Which admission order should the nurse question?

d. Combined clopidogrel and omeprazole therapy (Because the antiplatelet effect of clopidogrel is REDUCED when it is used with omeprazole, the nurse should clarify this prescription with the health care provider. The other interventions are appropriate for a patient with peripheral artery disease.)

30. Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

d. Help the patient to use a pillow to splint while coughing. (Assisting a patient who has already been taught how to cough is part of routine postoperative care and within the education and scope of practice for UAP. Patient teaching and assessment of essential postoperative functions such as circulation and movement should be done by RNs.)

10. The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venous thromboembolism. Which action by the nurse to elevate the patient's feet is best?

d. One pillow is placed under the thighs and two pillows are placed under the lower legs. (The purpose of elevating the feet is to enhance venous flow from the feet to the right atrium, which is best accomplished by placing two pillows under the feet and one under the thighs.)

1. When discussing risk factor modification for a 63-year-old patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus discharge teaching on which patient risk factor?

d. Uncontrolled hypertension (All of the factors contribute to the patient's risk, but only hypertension can potentially be modified to decrease the patient's risk for further expansion of the aneurysm.)

6. A patient at the clinic says, "I have always taken a walk after dinner, but lately my leg cramps and hurts after just a few minutes of starting. The pain goes away after I stop walking, though." The nurse should

d. assess for the presence of the dorsalis pedis and posterior tibial pulses. (The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication.)

3. Several hours after an open surgical repair of an abdominal aortic aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has been 40 mL. The nurse notifies the health care provider and anticipates an order for a(n)

d. blood urea nitrogen (BUN) level. (The decreased urine output suggests decreased renal perfusion, and monitoring of renal function is needed. There is no indication that infection is a concern, so antibiotic therapy and a WBC count are not needed. The I.V rate may be increased because hypovolemia may be contributing to the patient's decreased urinary output.)

5. A 73-year-old patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. The nurse should notify the health care provider and immediately

d. keep the patient in bed in the supine position. (The patient's history and clinical manifestations are consistent with acute arterial occlusion, and resting the leg will decrease the oxygen demand of the tissues and minimize ischemic damage until circulation can be restored. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the leg.)