Peripheral Venous Disease med surg questions

Which assessment data would support that the client has a venous stasis ulcer? 1. A superficial pink open area on the medial part of the ankle. 2. A deep pale open area over the top side of the foot. 3. A reddened blistered area on the heel of the foot. 4. A necrotic gangrenous area on the dorsal side of the foot.

1. The medial part of the ankle usually ulcerates because of edema that leads to stasis, which, in turn, causes the skin to break down.

The nurse is completing a neurovascular assessment on the client with chronic venous insufficiency. What should be included in this assessment? Select all that apply. 1. Assess for paresthesia. 2. Assess for pedal pulses. 3. Assess for paralysis. 4. Assess for pallor. 5. Assess for polar.

1. The nurse should determine if the client has any numbness or tingling. 2. The nurse should determine if the client has pulses, the presence of which indicates there is no circulatory compromise. 3. The nurse should determine if the client can move the feet and legs. 4. The nurse should determine if the client's feet are pink or pale. 5. The nurse should assess the feet to determine if they are cold or warm.

The client with varicose veins asks the nurse, "What caused me to have these?" Which statement by the nurse would be most appropriate? 1. "You have incompetent valves in your legs." 2. "Your legs have decreased oxygen to the muscle." 3. "There is an obstruction in the saphenous vein." 4. "Your blood is thick and can't circulate properly."

1. Varicose veins are irregular, tortuous veins with incompetent valves that do not allow the venous blood to ascend the saphenous vein.

Which client would be most at risk for developing varicose veins? 1. A Caucasian female who is a nurse. 2. An African American male who is a bus driver. 3. An Asian female with no children. 4. An elderly male with diabetes.

1. Varicose veins are more common in white females in occupations that involve prolonged standing.

The unlicensed assistive personnel (UAP) is caring for the client diagnosed with chronic venous insufficiency. Which action would warrant immediate intervention from the nurse? 1. Removing compression stockings before assisting the client to bed. 2. Taking the client's blood pressure manually after using the machine. 3. Assisting the client by opening the milk carton on the lunch tray. 4. Calculating the client's shift intake and output with a pen and paper.

1. Research shows that removing the compression stockings while the client is in bed promotes perfusion of the subcutaneous tissue. The foot of the bed should be elevated.

The nurse is caring for the client with chronic venous insufficiency. Which statement indicates the client understands the discharge teaching? 1. "I shouldn't cross my legs for more than 15 minutes." 2. "I need to elevate the foot of my bed while sleeping." 3. "I should take a baby aspirin every day with food." 4. "I should increase my fluid intake to 3,000 mL a day."

2. Elevating the foot of the bed while sleeping helps the venous blood return to the heart and decreases pressure in the lower extremity.

The client with varicose veins is six (6) hours postoperative vein ligation. Which nursing intervention should the nurse implement first? 1. Assist the client to dangle the legs off the side of the bed. 2. Assess and maintain pressure bandages on the affected leg. 3. Apply a sequential compression device to the affected leg. 4. Administer the prescribed prophylactic intravenous antibiotic

2. Pressure bandages are applied for up to six (6) weeks after vein ligation to help prevent bleeding and to help venous return from the lower extremities when in the standing or sitting position.

The 80-year-old client is being discharged home after having surgery to débride a chronic venous ulcer on the right ankle. Which referral would be most appropriate for the client? 1. Occupational therapist. 2. Social worker. 3. Physical therapist. 4. Cardiac rehabilitation.

2. The social worker would assess the client to determine if home health care services or financial interventions were appropriate for the client. The client is elderly, immobility is a concern, and wound care must be a concern when the client is discharged home.

The nurse has just received the a.m. shift report. Which client would the nurse assess first? 1. The client with a venous stasis ulcer who is complaining of pain. 2. The client with varicose veins who has dull aching muscle cramps. 3. The client with arterial occlusive disease who cannot move the foot. 4. The client with deep vein thrombosis who has a positive Homans' sign.

3. The inability to move the foot means that a severe neurovascular compromise has occurred, and the nurse should assess this client first.

The nurse is teaching a class on venous insufficiency. The nurse would identify which condition as the most serious complication of chronic venous insufficiency? 1. Arterial thrombosis. 2. Deep vein thrombosis. 3. Venous ulcerations. 4. Varicose veins.

3. Venous ulcerations are the most serious complication of chronic venous insufficiency. It is very difficult for these ulcerations to heal, and often clients must be seen in wound care clinics for treatment.

Which assessment data would the nurse expect to find in the client diagnosed with chronic venous insufficiency? 1. Decreased pedal pulses. 2. Cool skin temperature. 3. Intermittent claudication. 4. Brown discolored skin.

4. Chronic venous insufficiency leads to chronic edema that, in turn, causes a brownish pigmentation to the skin.

The client is employed in a job that requires extensive standing. Which intervention should the nurse include when discussing how to prevent varicose veins? 1. Wear low-heeled, comfortable shoes. 2. Wear clean white cotton socks. 3. Move the legs back and forth often. 4. Wear graduated compression hose.

4. Graduated compression hose help decrease edema and increase the circulation back to the heart; this helps prevent varicose veins.