PVD

A nurse is completing the admission assessment of a client with PAD. Which assessments will the nurse observe? (Select all that apply). 1. Absence of hair on the toes 2. Superficial ulcer with irregular edges 3. Pitting edema of the lower extremities 4. Reports of pain associated with exercising 5. Increased pigmentation of the medial malleolus area.

1, 4

What should the nurse expect the healthcare provider to prescribe for a patient who had clinical indicators of warfarin overdose? 1. Heparin 2. Vitamin K 3. Iron dextran 4. Protamine sulfate

2

A nurse has difficulty palpating the pedal pulse of a client with venous insufficiency. What action should the nurse take next? 1. Count the pulse at another site 2. Notify the PCP 3. Lower the legs to increase blood flow 4. Verify the pulse by using a Doppler.

4

To prepare a patient for surgery, which explanation by the nurse would be accurate related to pneumatic compression devices? A. They help the venous blood return to the heart. B. They will not cause discomfort, but gently massage the legs. C. They are used instead of anticoagulant therapy. D. They must be worn until the first time the patient gets out of bed.

A

A healthcare provider prescribes enoxaparin 30 mg subcutaneously daily. Which measure would the nurse take when administering this medication? a. Push over 2 minutes. b. Administer in the abdomen c. Rub site after administration d. Remove air pocket from prepackaged syringe before administration.

B

During an assessment, the client complains of tenderness when the nurse palpates the calf muscle. What would be the nurse's next assessment? A. To evaluate for any reduced hair growth. B. To evaluate for swelling, warmth, and muscle firmness. C. To assess for any history of ulcer formation around the calf muscle. D. To evaluate for venous distension in the posterolateral part of the ankle.

B

A patient is started on a heparin gtt. What finding does the nurse use to conclude that the intervention is therapeutic? a. International normalized ratio (INR) is between 2 and 3. b. Prothrombin time (PT) is 2.5 times the control value. c. Activated partial thromboplastin time (APTT) is double the control value. d. Activated clotting time (ACT) is the range of 70-120

C

The nurse is providing education about care of the residual limb for a patient who had a below-the-elbow amputation. Which information should be included in the teaching session? a. Wear a sling to bed every night. b. Apply lotion and massage it at least twice a day. c. Wash and dry the residual limb at least once a day. d. Soak the residual limb in warm water for 30 minutes each day.

C

A patient has been found to have an AAA. The client is immediately admitted to the hospital and surgery is scheduled for the next morning. Which assessment finding should the nurse expect this patient has? a. Signs of shock b. Visible peristaltic waves c. Radiating abdominal pain d. Pulsating abdominal mass

D