hinkle chapter 26 peripheral vascular and arterial disorders
In a client with a bypass graft, the distal outflow vessel must have at least what percentage patency for the graft to remain patent? 20 30 40 50
50 Explanation: The distal outflow vessel must be at least 50% patent for the graft to remain patent.
Approximately what percentage of the arterial lumen must be obstructed before intermittent claudication is experienced? 20 30 40 50
50 Explanation: Typically, about 50% of the arterial lumen or 75% of the cross-sectional area must be obstructed before intermittent claudication is experienced.
The nurse instructs a client with Raynaud phenomenon on actions to improve the symptoms. Which client statement indicates the need for additional instruction? "I will avoid stressful situations." "I will limit the amount of cigarettes I smoke." "I will put on gloves before opening a cold car door." "I will wear gloves when taking food out of the freezer."
"I will limit the amount of cigarettes I smoke." Explanation: Raynaud phenomenon is a form of intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of the fingertips or toes. Patients should avoid all forms of nicotine, which may induce attacks; this includes nicotine gum or patches used to aid smoking cessation. The client should be instructed to avoid situations that may be stressful as this could trigger an attack. Wearing gloves before opening a cold car door and when taking food out of the freezer should also be done as this could trigger vasoconstriction and an attack.
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? "Because my family is from Italy, I have a higher risk of developing peripheral arterial disease." "I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels." "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." "The older I get the higher my risk for peripheral arterial disease gets."
"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." Explanation: The use of tobacco products may be one of the most important risk factors in the development of atherosclerotic lesions. Nicotine in tobacco decreases blood flow to the extremities and increases heart rate and blood pressure by stimulating the sympathetic nervous system. This causes vasoconstriction, thereby decreasing arterial blood flow. It also increases the risk of clot formation by increasing the aggregation of platelets.
A client with peripheral arterial disease asks the nurse about using a heating pad to warm the feet. The nurse's best response is which of the following? "It is better to soak your feet in hot water as long as the water temperature is below 110 degrees F." "A heating pad to your feet is fine as long as the temperature stays below 105 degrees F." "A heating pad to your feet is a good idea because it increases the metabolic rate." "It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet."
"It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet." Explanation: It is safer to apply a heating pad to the abdomen, causing a reflex vasodilation in the extremities. Heat may be applied directly to ischemic extremities; however, the temperature of the heating source must not exceed body temperature. Excess heat may increase the metabolic rate of the extremities and increase the need for oxygen beyond that provided by the reduced arterial flow through the diseased artery.
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? A)"Enoxaparin will dissolve the clot, and warfarin will prevent any more clots from occurring." b)"The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect." c)"Because of the potential for a pulmonary embolism, it is important for you to take at least two anticoagulants." d)"Administration of two anticoagulants decreases the risk of recurrent venous thrombosis."
"The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect." Explanation: Oral anticoagulants such as warfarin are monitored by the prothrombin time (PT) or the international normalized ratio (INR). Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0).
You are presenting a workshop at the senior citizens center about how the changes of aging predisposes clients to vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in the older adult? Aneurysm Coronary thrombosis Atherosclerosis Raynaud's disease
Atherosclerosis Explanation: Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. Therefore, options A, B, and D are incorrect.
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? "As soon as you feel pain, we will go back and elevate your legs." "If you feel pain during the walk, keep walking until the end of the hallway is reached." "If you feel any discomfort, stop and we will use a wheelchair to take you back to your room." "Walk to the point of pain, rest until the pain subsides, then resume ambulation."
"Walk to the point of pain, rest until the pain subsides, then resume ambulation." Explanation: The nurse instructs the patient to walk to the point of pain, rest until the pain subsides, and then resume walking so that endurance can be increased as collateral circulation develops. Pain can serve as a guide in determining the appropriate amount of exercise.
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? 0.35 0.10 0.25 0.50
0.50 Explanation: After the circulatory status has been assessed and determined to be adequate for healing (ABI of more than 0.5) (Mosti, Iabichella, & Partsch, 2012), surgical dressings can be used to promote a moist environment.
Heparin therapy is usually considered therapeutic when the activated partial thromboplastin time (aPTT) is how many times higher than a normal value? 0.5 to 1.5 1.5 to 2.5 2.5 to 3.5 3.5 to 4.5
1.5 to 2.5 Explanation: Heparin therapy is usually considered therapeutic when the aPTT is 1.5 to 2.5 times the normal aPTT value. The other values are not within therapeutic range.
When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of: 3.5 times the baseline control. 2.5 to 3.0 times the baseline control. 4.5 times the baseline control. 1.5 to 2.5 times the baseline control.
1.5 to 2.5 times the baseline control. Explanation: A normal PTT level is 21 to 35 seconds. A reading of more than 100 seconds indicates a significant risk of hemorrhage.
The nurse is assessing a client with severe hypertension. Which symptom indicates to the nurse that the client is experiencing dissection of the aorta? A ripping sensation in the chest Pain when flexing the neck forward Numbness and pain of the left arm Gradual onset of a frontal headache
A ripping sensation in the chest Explanation: Aortic dissections are commonly associated with poorly controlled hypertension. Dissection is caused by rupture in the intimal layer. A rupture may occur through adventitia or into the lumen through the intima, allowing blood to reenter the main channel and resulting in chronic dissection or occlusion of branches of the aorta. The onset of symptoms is usually sudden and described as severe, persistent pain that feels like tearing or ripping. An aortic dissection does not cause pain and numbness of the left arm. Pain when flexing the neck forward is not associated with an aortic dissection. An aortic dissection does not cause a headache.
Which of the following medications is considered a thrombolytic? Lovenox Alteplase Coumadin Heparin
Alteplase Explanation: Alteplase is considered a thrombolytic, which lyses and dissolves thrombi. Thrombolytic therapy is most effective when given within the first 3 days after acute thrombosis. Heparin, Coumadin, and Lovenox do not lyse clots.
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: Urokinase. Alteplase. Reteplase. Streptokinase
Alteplase. Explanation: Alteplase has fewer disadvantages than the other thrombolytic agents. Refer to Table 18-2 in the text.
The nurse explains to a patient that the primary cause of a varicose vein is: Venospasm. Venous occlusion. An incompetent venous valve. Phlebothrombosis.
An incompetent venous valve. Explanation: Varicose veins are abnormally dilated, tortuous, superficial veins caused by incompetent venous valves.
To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the: Inside of the ankle just above the heel. Exterior surface of the foot near the heel. Outside of the foot just below the heel. Anterior surface of the foot near the ankle joint.
Anterior surface of the foot near the ankle joint. Explanation: The dorsalis pedis pulse can be palpated on the dorsal surface of the foot distal to the major prominence of the navicular bone.
You are assessing a client recently admitted to your unit for hypotension. While assessing this client, you find a pulsatile mass near the umbilicus. What would you suspect? Coronary artery disease Aortic aneurysm Raynaud's disease Peripheral artery disease
Aortic aneurysm Explanation: A pulsating mass may be felt or even seen around the umbilicus or to the left of midline over the abdomen. Options A, C, and D would not present with a pulsating mass near the umbilicus; therefore, they are incorrect.
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 Trauma Venous insufficiency Neither venous nor arterial
Arterial insufficiency Explanation: Characteristics of arterial insufficiency ulcers include location at the tips of the toes, extreme painfulness, and circular shape with pale to black ulcer bases. Ulcers caused by venous insufficiency will be irregular in shape, minimal pain if superficial (can be painful), and usually located around the ankles or the anterior tibial area.
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? Ask about any changes in skin color that occur in response to cold. Check for the presence of tortuous veins bilaterally on the legs. Attempt to palpate the dorsalis pedis and posterior tibial pulses. Assess for unilateral swelling and tenderness of either leg.
Attempt to palpate the dorsalis pedis and posterior tibial pulses. Explanation: Intermittent claudication is a sign of peripheral arterial insufficiency. The nurse should assess for other clinical manifestations of peripheral arterial disease in a client who describes intermittent claudication. A thorough assessment of the client's skin color and temperature and the character of the peripheral pulses are important in the diagnosis of arterial disorders.
Which of the following assessment results is considered a major risk factor for PAD? LDL of 100 mg/dL Triglyceride level of 150 mg/dL BP of 160/110 mm Hg Cholesterol of 200 mg/dL
BP of 160/110 mm Hg Hypertension is considered a major risk factor for PAD. Blood pressure should be less than 130/90 mm Hg. The other laboratory results are within the recommended range of normal to high normal.
Which of the following is a characteristic of an arterial ulcer? Ankle-brachial index (ABI) > 0.90 Border regular and well demarcated Edema may be severe Brawny edema
Border regular and well demarcated Explanation: Characteristics of an arterial ulcer include a border that is regular and demarcated. Brawny edema, ABI > 0.90, and edema that may be severe are characteristics of a venous ulcer.
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. Lack of exercise. Stress. Obesity.
Cigarette smoking. Explanation: 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.
The nurse is caring for a client recovering from acute axillary lymphangitis. Which treatment will the nurse anticipate being prescribed for this client after antibiotic therapy has concluded? Aspirin therapy Physical therapy Arm sling Compression sleeve
Compression sleeve Explanation: Lymphangitis is an acute inflammation of the lymphatic channels. It arises most commonly from a focal area of infection in an extremity caused by bacteria. At the conclusion of antibiotic therapy used for an acute attack, a graduated compression sleeve should be worn on the affected extremity for several months to prevent long-term edema. An arm sling is not required. The client will not need aspirin therapy as there is no surgery and/or risk of clots. The client will not need physical therapy as there should be no lingering effects from treatment of lymphangitis.
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) Angiography Magnetic resonance angiography (MRA) Doppler ultrasound
Computed tomography angiography (CTA) Explanation: A CTA is used to visualize arteries and veins and help assess for stenosis and occlusion.
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? Higher than normal blood pressure and falling hematocrit Constant, intense back pain and falling blood pressure Slow heart rate and high blood pressure Constant, intense headache and falling blood pressure
Constant, intense back pain and falling blood pressure Explanation: Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit.
As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client? Assess for the sites of bleeding. Demonstrate how to apply and remove elastic support stockings. Assess for skin integrity. Demonstrate how to self-administer IV infusions.
Demonstrate how to apply and remove elastic support stockings. Explanation: The nurse demonstrates how to apply and remove elastic support stockings. Varicose veins do not require the nurse to demonstrate how to self-administer IV infusions. Varicose veins require the client to elevate legs regularly and perform leg exercises. However, it does not involve bleeding or skin lesions.
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 Superficial ulcer Aching, cramping pain Pulses that are present but difficult to palpate
Diminished or absent pulses Explanation: Occlusive arterial disease impairs blood flow and can reduce or obliterate palpable pulsations in the extremities. A diminished or absent pulse is a characteristic of arterial insufficiency.
Which aneurysm results in bleeding into the layers of the arterial wall? False Dissecting Saccular Anastomotic
Dissecting Explanation: Dissection results from a rupture in the intimal layer, resulting in bleeding between the intimal and medial layers of the arterial wall. Saccular aneurysms collect blood in the weakened outpouching. In a false aneurysm, the mass is actually a pulsating hematoma. An anastomotic aneurysm occurs as a result of infection at arterial suture or graft sites.
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? Metoprolol (Lopressor) Hydrocortisone (Solu-Cortef) Cimetidine (Tagamet) Epinephrine
Epinephrine Explanation: Infrequently, a patient may have an immediate or delayed allergic reaction to the iodine contained in the contrast agent used in angiography. Manifestations include dyspnea, nausea and vomiting, sweating, tachycardia, and numbness of the extremities. Any such reaction must be reported to the interventionalist at once; treatment may include the administration of epinephrine, antihistamines, or corticosteroids.
Which statement is accurate regarding Raynaud disease? It is most common in men 16 to 40 years of age. It affects more than two digits on each hand or foot. Episodes may be triggered by unusual sensitivity to cold. The disease generally affects the client trilaterally.
Episodes may be triggered by unusual sensitivity to cold. Explanation: Episodes of Raynaud disease may be triggered by emotional factors or by unusual sensitivity to cold. The disease is most common in women between 16 and 40 years of age. It is generally unilateral and affects only one or two digits.
Which class of medication lyses and dissolves thrombi? Platelet inhibitors Anticoagulant Factor XA inhibitors Fibrinolytic
Fibrinolytic Explanation: Thrombolytic (fibrinolytic) therapy lyses and dissolves thrombi in 50% of clients. Anticoagulants, platelet inhibitors, and factor XA inhibitors do not lyse or dissolve thrombi.
A client with lower extremity edema is diagnosed with lymphedema. For which medication will the nurse prepare teaching for this client? Heparin Furosemide Oxycodone Amoxicillin
Furosemide Explanation: Lymphedema may be primary (congenital malformations) or secondary (acquired obstructions). Tissue swelling occurs in the extremities because of an increased quantity of lymph that results from obstruction of lymphatic vessels. As initial therapy, the diuretic furosemide may be prescribed to prevent fluid overload due to mobilization of extracellular fluid. Opioids are not used to treat lymphedema. Antibiotics would be prescribed only if an infection is present. Anticoagulants are not used to treat lymphedema.
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. Stent dislodgement. Decreased motor function. Thrombosis of the graft.
Hemorrhage. Explanation: All choices are serious and require medical/surgical intervention. However, hemorrhage is the most serious complication that requires immediate attention.
The nurse reviews the health history of a client with atherosclerosis. For which risk factors will the nurse prepare teaching for this client? Select all that apply. Genetic counseling High-fat diet Elevated blood pressure Use of nicotine products Exercise regimen
High-fat diet Exercise regimen Elevated blood pressure Use of nicotine products Explanation: Many risk factors are associated with atherosclerosis. Although it is not entirely clear whether modification of these risk factors prevents the development of cardiovascular disease, evidence indicates that it may slow the process, Because of this, the nurse will prepare teaching to address modifiable risk factors to include a high-fat diet, sedentary lifestyle, elevated blood pressure, and the use of nicotine products. Age is a nonmodifiable risk factor that cannot be changed.
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? Surgical debridement Vacuum-assisted closure device Enzymatic debridement Hyperbaric oxygen
Hyperbaric oxygen Explanation: Hyperbaric oxygenation (HBO) may be beneficial as an adjunct treatment in patients with diabetes with no signs of wound healing after 30 days of standard wound treatment. HBO is accomplished by placing the patient into a chamber that increases barometric pressure while the patient is breathing 100% oxygen. Treatment regimens vary from 90 to 120 minutes once daily for 30 to 90 sessions. The process by which HBO is thought to work involves several factors. The edema in the wound area is decreased because high oxygen tension facilitates vasoconstriction and enhances the ability of leukocytes to phagocytize and kill bacteria. In addition, HBO is thought to increase diffusion of oxygen to the hypoxic wound, thereby enhancing epithelial migration and improving collagen production.
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? Within 12 hours Within the first 24 hours In 2 days In 3 to 5 days
In 3 to 5 days Explanation: Oral anticoagulants, such as warfarin, are monitored by the PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0) (Holbrook et al., 2012).
Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending? Retrosternal back pain radiating to the left arm Decreased pulse rate and blood pressure Increased abdominal and back pain Elevated blood pressure and rapid respirations
Increased abdominal and back pain Explanation: Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be affected.
A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? Impaired gas exchange related to increased blood flow Excess fluid volume related to peripheral vascular disease Risk for injury related to edema Ineffective peripheral tissue perfusion related to venous congestion
Ineffective peripheral tissue perfusion related to venous congestion Explanation: Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with DVT. Impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Excess fluid volume related to peripheral vascular disease is inappropriate because there's no evidence that this client has an excess fluid volume. Risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion.
Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity? Acute limb ischemia Intermittent claudication Vertigo Dizziness
Intermittent claudication Explanation: 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. Acute limb ischemia is a sudden decrease in limb perfusion, which produces new or worsening symptoms that may threaten limb viability. Dizziness and vertigo are associated with upper extremity arterial occlusive disease.
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? Activated partial thromboplastin time (aPPT) is half of the control value K+ level is 3.5. International normalized ratio (INR) is 2.5. Prothrombin time (PT) is 0.5 times normal.
International normalized ratio (INR) is 2.5. Explanation: Oral anticoagulants such as warfarin are monitored by PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0)
Which observation regarding ulcer formation on the client's lower extremity indicates to the nurse that the ulcer is a result of venous insufficiency? Is deep, involving the joint space Large and superficial Base is pale to black Though superficial, is very painful
Large and superficial Explanation: Ulcerations are in the area of the medial or lateral malleolus (gaiter area) and are typically large, superficial, and highly exudative. Superficial venous insufficiency ulcers cause minimal pain. The base of a venous insufficiency ulcer shows a beefy red to yellow fibrinous color.
A nurse assesses a patient for a possible abdominal aortic aneurysm (AAA). Which of the following signs would the nurse recognize as positive indicators? Select all that apply. A systolic bruit Low back pain An abdominal pulsatile mass Lower abdominal pain Radiating chest pain Hypertension
Low back pain Lower abdominal pain An abdominal pulsatile mass A systolic bruit Explanation: Chest pain and hypertension, although they may be present, are not indicators of AAA even if present. All other choices are positive.
The nurse is caring for a patient with peripheral arterial insufficiency. What can the nurse suggest to help relieve leg pain during rest? Lowering the limb so that it is dependent Placing the limb in a plane horizontal to the body Elevating the limb above heart level Massaging the limb after application of cold compresses
Lowering the limb so that it is dependent Explanation: Persistent pain in the forefoot (i.e., the anterior portion of the foot) when the patient is resting indicates a severe degree of arterial insufficiency and a critical state of ischemia. Known as rest pain, this discomfort is often worse at night and may interfere with sleep. This pain frequently requires that the extremity be lowered to a dependent position to improve perfusion to the distal tissues.
With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by: Elevating the limb over the heart level. Massaging the limb after application of cold compresses. Lowering the limb so that it is dependent. Placing the limb in a plane horizontal to the body.
Lowering the limb so that it is dependent. Explanation: Lowering the extremity to a dependent position improves perfusion to the distal tissues.
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? Tissue loss to that foot Moderate to severe arterial insufficiency Very mild arterial insufficiency No arterial insufficiency
Moderate to severe arterial insufficiency Explanation: Normal people without arterial insufficiency have an ABI of about 1.0. Those with an ABI of 0.95 to 0.5 have mild to moderate arterial insufficiency. Those with an ABI of less than 0.50 have ischemic rest pain. Those with tissue loss have severe ischemia and an ABI of 0.25 or less.
Aortic dissection may be mistaken for which of the following disease processes? Stroke Pneumothorax Myocardial infarction (MI) Angina
Myocardial infarction (MI) Explanation: Aortic dissection may be mistaken for an acute MI, which could confuse the clinical picture and initial treatment. Aortic dissection is not mistaken for stroke, pneumothorax, or angina.
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? Enzymatic debridement Surgical debridement Selective debridement Nonselective debridement
Nonselective debridement Explanation: Nonselective débridement can be accomplished by applying isotonic saline dressings of fine mesh gauze to the ulcer. When the dressing dries, it is removed (dry), along with the debris adhering to the gauze. Pain management is usually necessary.
A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment? Swelling, warm skin temperature, and drainage Redness, cool skin temperature, and swelling Numbness, warm skin temperature, and redness Numbness, cool skin temperature, and pallor
Numbness, cool skin temperature, and pallor Explanation: Signs and symptoms of impaired circulation include numbness and cool, pale skin. Signs of localized infection may include swelling, drainage, redness, and warm skin. Signs of adequate circulation include normal sensation and warm skin with normal return of skin color after blanching.
A client who is diagnosed with Raynaud syndrome reports cold and numbness in the fingers. Which finding should the nurse identify as an early sign of vasoconstriction? Gangrene Ulceration Cyanosis Pallor
Pallor Explanation: Pallor is the initial symptom in Raynaud syndrome followed by cyanosis and aching pain. Gangrene and ulceration can occur with persistent attacks and interference of blood flow.
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. Massage the calf muscles if pain occurs. Use a heating pad to promote warmth. Keep the extremities elevated slightly.
Participate in a regular walking program. Explanation: Clients diagnosed with peripheral arterial occlusive disease should be encouraged to participate in a regular walking program to help develop collateral circulation. They should be advised to rest if pain develops and to resume activity when pain subsides. Extremities should be kept in a dependent position to promote circulation; elevation of the extremities will decrease circulation. Heating pads should not be used by anyone with impaired circulation to avoid burns. Massaging the calf muscles will not decrease pain. Intermittent claudication subsides with rest.
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: Internal iliac. Common femoral. Posterior tibial. Popliteal.
Posterior tibial. Explanation: Clinical symptoms of PAD are manifested in organs or muscle groups supplied by specific arterial blood flow. The posterior tibial artery is a major artery that is a common site for occlusion.
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? Plasma protein fraction Thrombin Phytonadione (vitamin K) Protamine sulfate
Protamine sulfate Explanation: Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn't given orally.) Thrombin is a hemostatic agent used to control local bleeding. 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.
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 History of increased aspirin use A history of diabetes mellitus An active daily walking program
Recent pelvic surgery Explanation: The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes mellitus is a contributing factor associated with peripheral vascular disease.
The nurse is caring for a client with abdominal aortic aneurysm (AAA). Which assessment finding is most likely to indicate a dissection of the aneurysm? Severe pain Hypertensive crisis Rectal bleeding Hematemesis
Severe pain Explanation: Pressure from an enlarging or dissecting abdominal aortic aneurysm is likely to be exhibited as severe pain. A decrease in blood pressure will result as the client goes into shock from hemorrhaging. Blood in emesis or rectal bleeding is not associated with rupture of AAA.
A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions? Decreasing blood pressure and increasing mobility Increasing blood pressure and monitoring fluid intake and output Stabilizing heart rate and blood pressure and easing anxiety Increasing blood pressure and reducing mobility
Stabilizing heart rate and blood pressure and easing anxiety Explanation: For a client with an aneurysm, nursing interventions focus on preventing aneurysm rupture by stabilizing heart rate and blood pressure. Easing anxiety also is important because anxiety and increased stimulation may raise the heart rate and boost blood pressure, precipitating aneurysm rupture. The client with an abdominal aortic aneurysm is typically hypertensive, so the nurse should take measures to lower blood pressure, such as administering antihypertensive agents, as ordered, to prevent aneurysm rupture. To sustain major organ perfusion, the client should maintain a mean arterial pressure of at least 60 mm Hg. Although the nurse must assess each client's mobility individually, most clients need bed rest when initially attempting to gain stability.
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. Wear antiembolic stockings daily to assist with blood return to the heart. Keep your feet elevated above your heart. Do not cross your legs for more than 30 minutes at a time.
Stop smoking. Explanation: Nicotine from tobacco products causes vasospasm and can thereby dramatically reduce circulation to the extremities. When the client elevates the feet above the heart level, the heart must work against gravity to supply blood to the feet. Antiembolic stocking are helpful for venous return to the heart, but constriction is not helpful for lack of arterial blood flow. Crossing the legs for more than a few minutes at a time compresses arteries and decreases blood supply to the legs and feet.
A client is diagnosed with a large thoracic aneurysm. Which findings will the nurse expect when assessing this client? Select all that apply. Reduced radial pulses Brassy cough Hoarse voice Stridor Aphonia
Stridor Hoarse voice Brassy cough Aphonia Explanation: The thoracic area is the most common site for a dissecting aneurysm. Symptoms vary and depend on how rapid the aneurysm dilates and how the pulsating mass affects surrounding structures. Symptoms of this type of aneurysm include stridor caused by pressure of the aneurysm against the trachea. Other symptoms include a hoarse voice, a brassy cough, and aphonia (or loss of voice) caused by pressure on the laryngeal nerve. A thoracic aneurysm does not affect pulses in the arms.
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 Abstaining from foods that increase levels of high-density lipoproteins (HDLs) Engaging in anaerobic exercise Reducing daily fat intake to less than 45% of total calories
Taking daily walks Explanation: Taking daily walks relieves symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may make these symptoms worse. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat, not abstain from, foods that raise HDL levels.
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. Inform the physician if the client's temperature remains low. Avoid elevating the area. Offer cold applications to promote comfort and to enhance circulation.
Teach the client how to apply a graduated compression stocking. Explanation: In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the client how to apply a graduated compression 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.
What should the nurse do to manage the persistent swelling in a client with severe lymphangitis and lymphadenitis? Inform the physician if the client's temperature remains low Offer cold applications to promote comfort and to enhance circulation Avoid elevating the area Teach the client how to apply an elastic sleeve
Teach the client how to apply an elastic sleeve Explanation: 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.
A client with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which is the most likely cause? The aneurysm may be preparing to rupture. The aneurysm has become obstructed. The client is experiencing normal sensations associated with this condition. The client is experiencing inflammation of the aneurysm.
The aneurysm may be preparing to rupture. Explanation: Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Abdominal pain is often localized to the middle or lower abdomen to the left of the midline. Low-back pain may be present because of pressure of the aneurysm on the lumbar nerves. Indications of a rupturing AAA include constant, intense back pain; falling blood pressure; and decreasing hematocrit. Rupture into the peritoneal cavity is quickly fatal. A retroperitoneal rupture of an aneurysm may result in hematomas in the scrotum, perineum, flank, or penis.
A pregnant client who developed 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? A)The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising. B)The client is pregnant and receiving I.V. heparin, placing her at risk for premature labor; the care plan should include reporting signs of premature labor. c)The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include sequential compression device application and strict bed rest. d) The client is at risk for developing another DVT
The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising. Explanation: Feedback about possible bleeding and bruising from physical therapy and other caregivers should be incorporated into the care plan to ensure safety and optimal outcomes. Using a sequential compression device, mandating strict bed rest, and reporting signs of DVT don't incorporate collaborative care. Reporting signs of premature labor doesn't address the consequences of thrombocytopenia, which may occur with I.V. heparin therapy.
Which of the following is the most common site for a dissecting aneurysm? Sacral area Lumbar area Cervical area Thoracic area
Thoracic area Explanation: The thoracic area is the most common site for a dissecting aneurysm. About one-third of patients with thoracic aneurysms die of rupture of the aneurysm.
The nurse is caring for a patient with venous insufficiency. For what should the nurse assess the patient's lower extremities? Ulceration Rubor Dermatitis Cellulitis
Ulceration Explanation: Venous ulceration is the most serious complication of chronic venous insufficiency and can be associated with other conditions affecting the circulation of the lower extremities. Cellulitis or dermatitis may complicate the care of chronic venous insufficiency and venous ulcerations.
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 Evident scaring Cyanosis Loose and wrinkled skin
Ulcers and infection in the edematous area Explanation: In a client with lymphedema, the tissue nutrition is impaired as a result of the stagnation of lymphatic fluid, leading to ulcers and infection in the edematous area. Later, the skin also appears thickened, rough, and discolored. Scaring does not occur in clients with lymphedema. Cyanosis is a bluish discoloration of the skin and mucous membranes.
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 Cyanosis Loose and wrinkled skin Evident scarring
Ulcers and infection in the edematous area Explanation: In a client with lymphedema, the tissue nutrition is impaired because of the stagnation of lymphatic fluid, leading to ulcers and infection in the edematous area. Later, the skin also appears thickened, rough, and discolored. Scarring does not occur in clients with lymphedema. Cyanosis is a bluish discoloration of the skin and mucous membranes.
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 gaiter 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? Trauma Arterial insufficiency Neither venous nor arterial insufficiency Venous insufficiency
Venous insufficiency Explanation: Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gaiter area, and a reddish blue color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the anterior tibial area. Characteristics of arterial insufficiency ulcers include location at the tips of the toes, great pain, and circular shape with a pale to black ulcer base.
The nurse is teaching a client who has been newly diagnosed with Raynaud syndrome. Which self-care strategies should the nurse include in the teaching? Select all that apply. Refrain from going outdoors in cold weather. Wear gloves to protect the hands from injury when performing tasks. Do not smoke, or stop smoking. Reduce emotional triggers. Limit activities that place stress on the ulnar nerve.
Wear gloves to protect the hands from injury when performing tasks. Do not smoke, or stop smoking. Reduce emotional triggers. Explanation: The nurse instructs clients with Raynaud syndrome to refrain from smoking, reduce emotional triggers, protect hands and feet from injury, and wear warm socks and mittens when going outdoors in cold weather. Stress on the ulnar nerve will not cause pain associated with Raynaud syndrome.
The nurse is caring for a client who is known to have a high risk for venous thromboembolism. What preventive actions should the nurse recommend? Select all that apply. High-protein diet Weight loss Regular exercise Calcium and vitamin D supplementation Smoking cessation
Weight loss Regular exercise Smoking cessation Explanation: Clients at risk for VTE should be advised to make lifestyle changes, as appropriate, which may include weight loss, smoking cessation, and regular exercise. Increased protein intake and supplementation with vitamin D and calcium do not address the main risk factors for VTE.
A client with a history of aching leg pain seeks medical attention for the development of a leg wound. Which assessment findings indicate to the nurse that the client is experiencing a venous ulcer? Select all that apply. Wound has an irregular border Thick, tough skin around the ankles Wound base is pale in color Darkened skin around the lower extremities Wound is superficial
Wound is superficial Wound has an irregular border Thick, tough skin around the ankles Darkened skin around the lower extremities Explanation: Aching leg pain is a symptom of venous insufficiency. Assessment findings that indicate the client is experiencing a venous ulcer include the wound is superficial with an irregular border. Thick skin around the ankles and darkened skin around the lower extremities are additional symptoms of venous insufficiency. A pale wound base is associated with an arterial ulcer.
Which client with a venous stasis ulcer is a candidate for topical hyperbaric oxygen therapy? a client with a chronic, nonhealing skin lesion a client with an infected stasis ulcer a nonambulatory client a client whose ulcer includes necrotic tissue
a client with a chronic, nonhealing skin lesion Explanation: Chronic, nonhealing skin lesions are treated with topical hyperbaric oxygen therapy. This approach delivers oxygen above atmospheric pressure directly to the wound rather than to the full body as with other disorders such as carbon monoxide poisoning. Necrotic tissue is debrided from a stasis ulcer. A client's infection is treated with an application of Silvadene, an antibacterial cream, or an antibiotic ointment and an occlusive transparent dressing such as Tegaderm that traps moisture and speeds healing.
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: decreases venous congestion. increases high-density lipoprotein (HDL) level. aids in weight reduction. reduces stress.
decreases venous congestion. Explanation: Regular walking is the best way to decrease venous congestion because using the leg muscles as a pump helps return blood to the heart. Regular exercise also aids in stress reduction and weight reduction and increases the formation of HDLs — which are all beneficial to a client with peripheral vascular disease. However, these changes don't have as significant an effect on the client's condition as decreasing venous congestion.
A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: elevating the extremity to prevent pooling of blood. providing warmth to the extremity. forcing blood into the deep venous system. encouraging ambulation to prevent pooling of blood.
forcing blood into the deep venous system. Explanation: Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn't a function of the stockings. Antiembolism stockings could possibly provide warmth, but this factor isn't how they prevent DVT. Elevating the extremity decreases edema but doesn't prevent DVT.
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. place a heating pad around the affected calf. elevate the affected leg as high as possible. shave the affected leg in anticipation of surgery.
keep the affected leg level or slightly dependent. Explanation: While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg could cause accidental trauma from cuts or nicks.
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: match the room temperature to the client's body temperature. maintain room temperature at 78° F (25.6° C). keep the client warm. keep the client uncovered.
keep the client warm. Explanation: The nurse should keep the client covered and expose only the portion of the client's body that she's assessing. The nurse should also keep the client warm by maintaining his room temperature between 68° F and 74° F (20° and 23.3° C). Extreme temperatures aren't good for clients with PVD. The valves in their arteries and veins are already insufficient, and exposing them to vast changes in temperature could affect assessment findings. Keeping the client uncovered would cause him to become chilled. Matching the room temperature to the client's body temperature is inappropriate.
