Vascular Disorders

The nurse is teaching the client precautions to take while on warfarin (Coumadin) therapy. Which statement made by the client demonstrates that teaching has been effective? A. "I can use an electric razor or a regular razor." B. "Eating foods like green beans won't interfere with my Coumadin therapy." C. "If I notice I am bleeding a lot, I should stop taking Coumadin right away." D. "When taking Coumadin, I may notice some blood in my urine."

"Eating foods like green beans won't interfere with my Coumadin therapy."

When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client states which of these? A. "I feel my heart beating in my abdominal area." B. "I just started to feel a tearing pain in my belly." C. "I have a headache. May I have some acetaminophen?" D. "I have had hoarseness for a few weeks."

"I just started to feel a tearing pain in my belly."

The nurse is teaching the young female client how to prevent venous thromboembolism specific to her hospital stay after intensive orthopedic surgery. Which statement made by the client indicates the need for further teaching? A. "I must stop taking my birth control pills." B. "I should drink lots of water so I don't get dehydrated." C. "I should exercise my legs when I have been sitting or standing for a long time." D. "If I wear pantyhose, I won't have to wear the stockings the hospital gives me."

"If I wear pantyhose, I won't have to wear the stockings the hospital gives me."

The client has just undergone arterial revascularization. Which statement by the client indicates a need for further teaching related to postoperative care? A. "My leg might turn very white after the surgery." B. "I should be concerned if my foot turns blue." C. "I should report a fever or any drainage." D. "Warmness, redness, and swelling are expected."

"My leg might turn very white after the surgery."

The client undergoing femoral popliteal bypass states that he is fearful he will lose the limb in the near future. Which response by the nurse is most therapeutic? A. "Are you afraid you will not be able to work?" B. "If you control your diabetes, you can avoid amputation." C. "Your concerns are valid; we can review some steps to limit disease progression." D. "What about the situation concerns you most?"

"Your concerns are valid; we can review some steps to limit disease progression."

A desirable LDL-C level is one below _______ for healthy people and below _______for those diagnosed with CVD or who are diabetic.

100 mg/dL 70 mg/dL

Patients with diabetes and heart disease should have a blood pressure below

130/90

Total serum cholesterol levels should be below

200 mg/dL. Healthy range is 122-200 mg/dL

Normal range for triglycerides

35-160

A desirable HDL-C level is

40 mg/dL or above

intermittent claudication

A characteristic leg pain experienced by patients with chronic peripheral arterial disease. Typically, patients can walk only a certain distance before a cramping muscle pain forces them to stop. As the disease progresses, the patient can walk only shorter and shorter distances before pain recurs. Ultimately, pain may occur even at rest.

metabolic syndrome

A collection of related health problems with insulin resistance as a main feature. Other features include obesity, low levels of physical activity, hypertension, high blood levels of cholesterol, and elevated triglyceride levels. Metabolic syndrome increases the risk for coronary heart disease. Also called "syndrome X."

venous duplex ultrasonography

A noninvasive test using ultrasonic waves; the preferred diagnostic test for deep vein thrombosis.

percutaneous transluminal angioplasty (PTA)

A nonsurgical method of improving arterial flow by opening the vessel lumen and creating a smooth inner vessel surface. One or more arteries are dilated with a balloon catheter advanced through a cannula, which is inserted into or above an occluded or stenosed artery.

arterial ulcers

A painful complication in the patient with peripheral arterial disease. Typically, the ulcer is small and round, with a "punched out" appearance and well-defined borders. Ulcers develop on the toes (often the great toe), between the toes, or on the upper aspect of the foot. With prolonged occlusion, the toes can become gangrenous.

aneurysm

A permanent localized dilation of an artery (to at least two times its normal diameter) that forms when the middle layer (media) of the artery is weakened, stretching the inner (intima) and outer (adventitia) layers. As the artery widens, tension in the wall increases and further widening occurs, thus enlarging the aneurysm.

ankle-brachial index (ABI)

A ratio derived by dividing the ankle blood pressure by the brachial blood pressure; this calculation is used to assess the vascular status of the lower extremities. To obtain the ABI, a blood pressure cuff is applied to the lower extremities just above the malleoli. The systolic pressure is measured by Doppler ultrasound at both the dorsalis pedis and posterior tibial pulses. The higher of these two pressures is then divided by the higher of the two brachial pulses.

venous thromboembolism (VTE)

A term that refers to both deep vein thrombosis and pulmonary embolism; obstruction by a thrombus.

A 40-year-old man tells the nurse he has a diagnosis for the color and temperature changes of his limbs but can't remember the name of it. He says he must stop smoking and avoid trauma and exposure of his limbs to cold temperatures to get better. This description should allow the nurse to ask the patient if he has which diagnosis? A) Buerger's disease B) Venous thrombosis C) Acute arterial ischemia D) Raynaud's phenomenon

A) Buerger's disease is a nonatherosclerotic, segmental, recurrent inflammatory disorder of small and medium-sized veins and arteries of upper and lower extremities leading to color and temperature changes of the limbs, intermittent claudication, rest pain, and ischemic ulcerations. It primarily occurs in men younger than 45 years old with a long history of tobacco and/or marijuana use. Buerger's disease treatment includes smoking cessation, trauma and cold temperature avoidance, and a walking program. Venous thrombosis is the formation of a thrombus in association with inflammation of the vein. Acute arterial ischemia is a sudden interruption in arterial blood flow to a tissue caused by embolism, thrombosis, or trauma. Raynaud's phenomenon is characterized by vasospasm-induced color changes of the fingers, toes, ears, and nose.

The nurse is admitting a 68-year-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication? A) Vitamin K B) Cobalamin C) Heparin sodium D) Protamine sulfate

A) Coumadin is a Vitamin K antagonist anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin (Coumadin).

The patient has CVI and a venous ulcer. The unlicensed assistive personnel (UAP) decides to apply compression stockings because that is what these patients always have ordered. What assessment by the nurse would cause the application of compression stockings to harm the patient? A) Rest pain B) High blood pressure C) Elevated blood sugar D) Dry, itchy, flaky skin

A) Rest pain occurs as peripheral artery disease (PAD) progresses and involves multiple arterial segments. Compression stockings should not be used on patients with PAD. Elevated blood glucose, possibly indicating uncontrolled diabetes mellitus, and hypertension may or may not indicate arterial problems. Dry, itchy, flaky skin indicates venous insufficiency. The RN should be the one to obtain the order and instruct the UAP to apply compression stockings if they are ordered.

When the patient is being examined for venous thromboembolism (VTE) in the calf, what diagnostic test should the nurse expect to teach the patient about first? A) Duplex ultrasound B) Contrast venography C) Magnetic resonance venography D) Computed tomography venography

A) The duplex ultrasound is the most widely used test to diagnose VTE. Contrast venography is rarely used now. Magnetic resonance venography is less accurate for calf veins than pelvic and proximal veins. Computed tomography venography may be used but is invasive and much more expensive than the duplex ultrasound.

Assessment of a patient's peripheral IV site reveals that phlebitis has developed over the past several hours. Which intervention should the nurse implement first? A) Remove the patient's IV catheter. B) Apply an ice pack to the affected area. C) Decrease the IV rate to 20 to 30 mL/hr. D) Administer prophylactic anticoagulants.

A) The priority intervention for superficial phlebitis is removal of the offending IV catheter. Decreasing the IV rate is insufficient. Anticoagulants are not normally required, and warm, moist heat is often therapeutic.

The nurse is reviewing the laboratory test results for a 68-year-old patient whose warfarin (Coumadin) therapy was terminated during the preoperative period. The nurse concludes that the patient is in the most stable condition for surgery after noting which INR (international normalized ratio) result? A) 1.0 B) 1.8 C) 2.7 D) 3.4

A) The therapeutic range for INR is 2.0 to 3.0 for many clinical diagnoses. The larger the INR number, the greater the amount of anticoagulation. For this reason, the safest value before surgery is 1.0, meaning that the anticoagulation has been reversed.

What medications should the nurse expect to include in the teaching plan to decrease the risk of cardiovascular events and death for PAD patients (select all that apply)? A) Ramipril (Altace) B) Cilostazol (Pletal) C) Simvastatin (Zocor) D) Clopidogrel (Plavix) E) Warfarin (Coumadin) F) Aspirin (acetylsalicylic acid)

A, F) Angiotensin-converting enzyme inhibitors (e.g., ramipril [Altace]) are used to control hypertension. Statins (e.g., simvastatin [Zocor]) are used for lipid management. Aspirin is used as an antiplatelet agent. Cilostazol (Pletal) is used for intermittent claudication, but it does not reduce CVD morbidity and mortality risks. Clopidogrel may be used if the patient cannot tolerate aspirin. Anticoagulants (e.g., warfarin [Coumadin]) are not recommended to prevent CVD events in PAD patients.

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).

ANS: 0.76 The ABI is calculated by dividing the ankle systolic BP by the brachial systolic BP.

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 b. Control of serum lipid levels c. Maintenance of appropriate weight d. Demonstration of meticulous foot care

ANS: A 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.

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." b. "I can't seem to ever get my feet warm enough." c. "I have burning leg pains after I walk two blocks." d. "I wake up during the night because my legs hurt."

ANS: A Because the edema associated with venous insufficiency increases when the patient has been standing, shoes will feel tighter at the end of the day. The other patient statements are characteristic of peripheral artery disease (PAD).

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 b. Antibiotics c. Thrombolytics d. Anticoagulants

ANS: A Current research indicates that statin use by patients with PAD improves multiple outcomes. There is no research that supports the use of the other medication categories in PAD.

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 b. Antibiotics c. Thrombolytics d. Anticoagulants

ANS: A Current research indicates that statin use by patients with PAD improves multiple outcomes. There is no research that supports the use of the other medication categories in PAD.

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. b. The patient places the hands in hot water when they turn pale. c. The patient takes pseudoephedrine (Sudafed) for cold symptoms. d. The patient avoids taking nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: A 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.

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. b. The LPN/LVN assists the patient to walk 40 feet in the hallway. c. The LPN/LVN gives the ordered aspirin 160 mg after breakfast. d. The LPN/LVN places the patient in a Fowler's position for meals.

ANS: A 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.

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. b. The LPN/LVN assists the patient to walk 40 feet in the hallway. c. The LPN/LVN gives the ordered aspirin 160 mg after breakfast. d. The LPN/LVN places the patient in a Fowler's position for meals.

ANS: A 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.

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 a. have to buy some loose clothes that do not bind across my legs or waist." b. use a heating pad on my feet at night to increase the circulation and warmth in my feet." c. change my position every hour and avoid long periods of sitting with my legs crossed." d. walk to the point of pain, rest, and walk again until the pain returns for at least 30 minutes 3 times a week."

ANS: B Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. The other patient statements are correct and indicate that teaching has been successful.

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 a. have to buy some loose clothes that do not bind across my legs or waist." b. use a heating pad on my feet at night to increase the circulation and warmth in my feet." c. change my position every hour and avoid long periods of sitting with my legs crossed." d. walk to the point of pain, rest, and walk again until the pain returns for at least 30 minutes 3 times a week."

ANS: B Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. The other patient statements are correct and indicate that teaching has been successful.

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? a. Begin oral intake. b. Obtain vital signs. c. Assess pedal pulses. d. Start discharge teaching.

ANS: B 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.

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? a. Begin oral intake. b. Obtain vital signs. c. Assess pedal pulses. d. Start discharge teaching.

ANS: B 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.

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 a. decrease the infusion when the PTT value is 65 seconds. b. avoid giving any IM medications to prevent localized bleeding. c. monitor posterior tibial and dorsalis pedis pulses with the Doppler. d. have vitamin K available in case reversal of the heparin is needed.

ANS: B 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.

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)? a. Patient who has been complaining of increased edema and skin changes in the legs b. Patient who needs wound care for a chronic venous stasis ulcer on the right lower leg c. Patient who has a history of venous thromboembolism and is complaining of some dyspnea d. Patient who needs teaching about the use of elastic compression stockings for venous insufficiency

ANS: B 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.

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? a. "Exercise only if you do not experience any pain." b. "It is very important that you stop smoking cigarettes." c. "Try to keep your legs elevated whenever you are sitting." d. "Put elastic compression stockings on early in the morning."

ANS: B Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death. Circulation to the legs will decrease if the legs are elevated. Patients with PAD are taught to exercise to the point of feeling pain, rest, and then resume walking. Support hose are not used for patients with PAD.

When developing a teaching plan for a 76-year-old patient newly diagnosed with peripheral artery disease (PAD), which instructions should the nurse include? a. "Exercise only if you do not experience any pain." b. "It is very important that you stop smoking cigarettes." c. "Try to keep your legs elevated whenever you are sitting." d. "Put elastic compression stockings on early in the morning."

ANS: B Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death. Circulation to the legs will decrease if the legs are elevated. Patients with PAD are taught to exercise to the point of feeling pain, rest, and then resume walking. Support hose are not used for patients with PAD.

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? a. Monitor for any bleeding after anticoagulation therapy is started. b. Apply sequential compression device whenever the patient is in bed. c. Ask the patient about use of herbal medicines or dietary supplements. d. Instruct the patient to call immediately if any shortness of breath occurs.

ANS: B 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 (RN).

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 a. dilated superficial veins. b. swollen, dry, scaly ankles. c. prolonged capillary refill in all the toes. d. a serosanguineous drainage from the ulcer.

ANS: C Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease.

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 a. dilated superficial veins. b. swollen, dry, scaly ankles. c. prolonged capillary refill in all the toes. d. a serosanguineous drainage from the ulcer.

ANS: C Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease.

Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? a. Erythema of right lower leg b. Complaint of right calf pain c. New onset shortness of breath d. Temperature of 100.4° F (38° C)

ANS: C 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 a. hyperglycemia. b. hyperlipidemia. c. autoimmune disorders. d. coronary artery disease.

ANS: C 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.

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 a. hyperglycemia. b. hyperlipidemia. c. autoimmune disorders. d. coronary artery disease.

ANS: C 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.

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? a. Use of treadmill for exercise b. Referral for dietary instruction c. Exercising to the point of discomfort d. Combined clopidogrel and omeprazole therapy

ANS: D 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.

A patient is being evaluated for post-thrombotic syndrome. Which assessment will the nurse perform? a. Ask about leg pain with exercise. b. Determine the ankle-brachial index. c. Assess capillary refill in the patient's toes. d. Check for presence of lipodermatosclerosis.

ANS: D 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.

Which topic should the nurse include in patient teaching for a patient with a venous stasis ulcer on the left lower leg? a. Need to increase carbohydrate intake b. Methods of keeping the wound area dry c. Purpose of prophylactic antibiotic therapy d. Application of elastic compression stockings

ANS: D Compression of the leg is essential to healing of venous stasis ulcers. High dietary intake of protein, rather than carbohydrates, is needed. Prophylactic antibiotics are not routinely used for venous ulcers. Moist dressings are used to hasten wound healing.

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? a. "When I stand too long, my feet start to swell." b. "I get short of breath when I climb a lot of stairs." c. "My fingers hurt when I go outside in cold weather." d. "My legs cramp whenever I walk more than a block."

ANS: D Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication. Finger pain associated with cold weather is typical of Raynaud's phenomenon. Shortness of breath that occurs with exercise is not typical of intermittent claudication, which is reproducible. Swelling associated with prolonged standing is typical of venous disease.

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 a. check for the presence of tortuous veins bilaterally on the legs. b. ask about any skin color changes that occur in response to cold. c. assess for unilateral swelling, redness, and tenderness of either leg. d. assess for the presence of the dorsalis pedis and posterior tibial pulses.

ANS: D The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud's phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness indicate venous thromboembolism (VTE).

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 a. check for the presence of tortuous veins bilaterally on the legs. b. ask about any skin color changes that occur in response to cold. c. assess for unilateral swelling, redness, and tenderness of either leg. d. assess for the presence of the dorsalis pedis and posterior tibial pulses.

ANS: D The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud's phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness indicate venous thromboembolism (VTE).

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 a. apply a compression stocking to the leg. b. elevate the leg above the level of the heart. c. assist the patient in gently exercising the leg. d. keep the patient in bed in the supine position.

ANS: D 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.

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 a. apply a compression stocking to the leg. b. elevate the leg above the level of the heart. c. assist the patient in gently exercising the leg. d. keep the patient in bed in the supine position.

ANS: D 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.

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? a. The patient is placed in the Trendelenburg position. b. Two pillows are positioned under the affected leg. c. The bed is elevated at the knee and pillows are placed under the feet. d. One pillow is placed under the thighs and two pillows are placed under the lower legs.

ANS: D 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. Placing the patient in the Trendelenburg position will lower the head below heart level, which is not indicated for this patient. Placing pillows under the calf or elevating the bed at the knee may cause blood stasis at the calf level

The nurse is caring for a client with dark-colored toe ulcers and blood pressure of 190/100. Which of these nursing actions should you delegate to the LPN/LVN? A. Assess leg ulcers for evidence of infection. B. Administer a clonidine patch for hypertension. C. Obtain a request from the doctor for a dietary consult. D. Develop a plan for discharge, and assess home care needs.

Administer a clonidine patch for hypertension.

atherectomy

An invasive nonsurgical technique in which a high-speed, rotating metal burr uses fine abrasive bits to scrape plaque from inside an artery while minimizing damage to the vessel surface.

The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain whenever she walks several blocks. The patient has type 1 diabetes and has smoked a pack of cigarettes every day for the past 40 years. The physician diagnoses intermittent claudication. The nurse should provide what instruction about long-term care to the client? A) "Be sure to practice meticulous foot care." B) "Consider cutting down on your smoking." C) "Reduce your activity level to accommodate your limitations." D) "Try to make sure you eat enough protein."

Ans: "Be sure to practice meticulous foot care." Feedback: The patient with peripheral vascular disease or diabetes should receive education or reinforcement about skin and foot care. Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing; therefore, meticulous foot care is essential. The patient should stop smoking—not just cut down—because nicotine is a vasoconstrictor. Daily walking benefits the patient with intermittent claudication. Increased protein intake will not alleviate the patient's symptoms.

A nurse in the rehabilitation unit is caring for an older adult patient who is in cardiac rehabilitation following an MI. The nurse's plan of care calls for the patient to walk for 10 minutes 3 times a day. The patient questions the relationship between walking and heart function. How should the nurse best reply? A) "The arteries in your legs constrict when you walk and allow the blood to move faster and with more pressure on the tissue." B) Walking increases your heart rate and blood pressure. Therefore your heart is under less stress." C) "Walking helps your heart adjust to your new arteries and helps build your self-esteem." D) "When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart."

Ans: "When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart." Feedback: Veins, unlike arteries, are equipped with valves that allow blood to move against the force of gravity. The legs have one-way bicuspid valves that prevent blood from seeping backward as it moves forward by the muscles in our legs pressing on the veins as we walk and increasing venous return. Leg arteries do constrict when walking, which allows the blood to move faster and with more pressure on the tissue, but the greater concern is increasing the flow of venous blood to the heart. Walking increases, not decreases, the heart' pumping ability, which increases heart rate and blood pressure and the hearts ability to manage stress. Walking does help the heart adjust to new arteries and may enhance self-esteem, but the patient had an MI—there are no "new arteries."

An older adult patient has been treated for a venous ulcer and a plan is in place to prevent the occurrence of future ulcers. What should the nurse include in this plan? A) Use of supplementary oxygen to aid tissue oxygenation B) Daily use of normal saline compresses on the lower limbs C) Daily administration of prophylactic antibiotics D) A high-protein diet that is rich in vitamins

Ans: A high-protein diet that is rich in vitamins Feedback: A diet that is high in protein, vitamins C and A, iron, and zinc is encouraged to promote healing and prevent future ulcers. Prophylactic antibiotics and saline compresses are not used to prevent ulcers. Oxygen supplementation does not prevent ulcer formation.

A medical nurse has admitted four patients over the course of a 12-hour shift. For which patient would assessment of ankle-brachial index (ABI) be most clearly warranted? A) A patient who has peripheral edema secondary to chronic heart failure B) An older adult patient who has a diagnosis of unstable angina C) A patient with poorly controlled type 1 diabetes who is a smoker D) A patient who has community-acquired pneumonia and a history of COPD

Ans: A patient with poorly controlled type 1 diabetes who is a smoker Feedback: Nurses should perform a baseline ABI on any patient with decreased pulses or any patient 50 years of age or older with a history of diabetes or smoking. The other answers do not apply.

The nurse is caring for a 72-year-old patient who is in cardiac rehabilitation following heart surgery. The patient has been walking on a regular basis for about a week and walks for 15 minutes 3 times a day. The patient states that he is having a cramp-like pain in the legs every time he walks and that the pain gets "better when I rest." The patient's care plan should address what problem? A) Decreased mobility related to VTE B) Acute pain related to intermittent claudication C) Decreased mobility related to venous insufficiency D) Acute pain related to vasculitis

Ans: Acute pain related to intermittent claudication Feedback: Intermittent claudication presents as a muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest. Patients with peripheral arterial insufficiency often complain of intermittent claudication due to a lack of oxygen to muscle tissue. Venous insufficiency presents as a disorder of venous blood reflux and does not present with cramp-type pain with exercise. Vasculitis is an inflammation of the blood vessels and presents with weakness, fever, and fatigue, but does not present with cramp-type pain with exercise. The pain associated with VTE does not have this clinical presentation.

A nurse on a medical unit is caring for a patient who has been diagnosed with lymphangitis. When reviewing this patient's medication administration record, the nurse should anticipate which of the following? A) Coumadin (warfarin) B) Lasix (furosemide) C) An antibiotic D) An antiplatelet aggregator

Ans: An antibiotic Feedback: Lymphangitis is an acute inflammation of the lymphatic channels caused by an infectious process. Antibiotics are always a component of treatment. Diuretics are of nominal use. Anticoagulants and antiplatelet aggregators are not indicated in this form of infection.

A 79-year-old man is admitted to the medical unit with digital gangrene. The man states that his problems first began when he stubbed his toe going to the bathroom in the dark. In addition to this trauma, the nurse should suspect that the patient has a history of what health problem? A) Raynaud's phenomenon B) CAD C) Arterial insufficiency D) Varicose veins

Ans: Arterial insufficiency Feedback: Arterial insufficiency may result in gangrene of the toe (digital gangrene), which usually is caused by trauma. The toe is stubbed and then turns black. Raynaud's, CAD and varicose veins are not the usual causes of digital gangrene in the elderly.

A patient who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the first postoperative day? A) Assess pulse of affected extremity every 15 minutes at first. B) Palpate the affected leg for pain during every assessment. C) Assess the patient for signs and symptoms of compartment syndrome every 2 hours. D) Perform Doppler evaluation once daily.

Ans: Assess pulse of affected extremity every 15 minutes at first. Feedback: The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the patient's status remains stable. Doppler evaluations should be performed every 2 hours. Pain is regularly assessed, but palpation is not the preferred method of performing this assessment. Compartment syndrome results from the placement of a cast, not from vascular surgery.

A nurse is creating an education plan for a patient with venous insufficiency. What measure should the nurse include in the plan? A) Avoiding tight-fitting socks. B) Limit activity whenever possible. C) Sleep with legs in a dependent position. D) Avoid the use of pressure stockings.

Ans: Avoiding tight-fitting socks. Feedback: Measures taken to prevent complications include avoiding tight-fitting socks and panty girdles; maintaining activities, such as walking, sleeping with legs elevated, and using pressure stockings. Not included in the teaching plan for venous insufficiency would be reducing activity, sleeping with legs dependent, and avoiding pressure stockings. Each of these actions exacerbates venous insufficiency.

A nurse is admitting a 45-year-old man to the medical unit who has a history of PAD. While providing his health history, the patient reveals that he smokes about two packs of cigarettes a day, has a history of alcohol abuse, and does not exercise. What would be the priority health education for this patient? A) The lack of exercise, which is the main cause of PAD. B) The likelihood that heavy alcohol intake is a significant risk factor for PAD. C) Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD. D) Alcohol suppresses the immune system, creates high glucose levels, and may cause PAD.

Ans: Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD. Feedback: Tobacco is powerful vasoconstrictor; its use with PAD is highly detrimental, and patients are strongly advised to stop using tobacco. Sedentary lifestyle is also a risk factor, but smoking is likely a more significant risk factor that the nurse should address. Alcohol use is less likely to cause PAD, although it carries numerous health risks.

A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of HF and peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse should implement measures to prevent what complication? A) Aoritis B) Deep vein thrombosis C) Thoracic aortic aneurysm D) Raynaud's disease

Ans: Deep vein thrombosis Feedback: Although the exact cause of venous thrombosis remains unclear, three factors, known as Virchow's triad, are believed to play a significant role in its development: stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation. In this woman's case, she has venous stasis from immobility, vessel wall injury from PAD, and altered blood coagulation from HF. The cause of aoritis is unknown, but it has no direct connection to HF, PAD, or mobility issues. The greatest risk factors for thoracic aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to HF, PAD, or mobility issues. Raynaud's disease is a disorder that involves spasms of blood vessels and, again, no direct connection to HF, PAD, or mobility issues.

When assessing venous disease in a patient's lower extremities, the nurse knows that what test will most likely be ordered? A) Duplex ultrasonography B) Echocardiography C) Positron emission tomography (PET) D) Radiography

Ans: Duplex ultrasonography Feedback: Duplex ultrasound may be used to determine the level and extent of venous disease as well as its chronicity. Radiographs (x-rays), PET scanning, and echocardiography are never used for this purpose as they do not allow visualization of blood flow.

The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission assessment that the patient takes oral contraceptives. Consequently, the nurse's postoperative plan of care should include what intervention? A) Early ambulation and leg exercises B) Cessation of the oral contraceptives until 3 weeks postoperative C) Doppler ultrasound of peripheral circulation twice daily D) Dependent positioning of the patient's extremities when at rest

Ans: Early ambulation and leg exercises Feedback: Oral contraceptive use increases blood coagulability; with bed rest, the patient may be at increased risk of developing deep vein thrombosis. Leg exercises and early ambulation are among the interventions that address this risk. Assessment of peripheral circulation is important, but Doppler ultrasound may not be necessary to obtain these data. Dependent positioning increases the risk of venous thromboembolism (VTE). Contraceptives are not normally discontinued to address the risk of VTE in the short term.

The nurse is evaluating a patient's diagnosis of arterial insufficiency with reference to the adequacy of the patient's blood flow. On what physiological variables does adequate blood flow depend? Select all that apply. A) Efficiency of heart as a pump B) Adequacy of circulating blood volume C) Ratio of platelets to red blood cells D) Size of red blood cells E) Patency and responsiveness of the blood vessels

Ans: Efficiency of heart as a pump, Adequacy of circulating blood volume, Patency and responsiveness of the blood vessels Feedback: Adequate blood flow depends on the efficiency of the heart as a pump, the patency and responsiveness of the blood vessels, and the adequacy of circulating blood volume. Adequacy of blood flow does not primarily depend on the size of red cells or their ratio to the number of platelets.

How should the nurse best position a patient who has leg ulcers that are venous in origin? A) Keep the patient's legs flat and straight. B) Keep the patient's knees bent to 45-degree angle and supported with pillows. C) Elevate the patient's lower extremities. D) Dangle the patient's legs over the side of the bed.

Ans: Elevate the patient's lower extremities. Feedback: Positioning of the legs depends on whether the ulcer is of arterial or venous origin. With venous insufficiency, dependent edema can be avoided by elevating the lower extremities. Dangling the patient's legs and applying pillows may further compromise venous return.

A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. What is the most appropriate intervention for this diagnosis? A) Elevate his legs and arms above his heart when resting. B) Encourage the patient to engage in a moderate amount of exercise. C) Encourage extended periods of sitting or standing. D) Discourage walking in order to limit pain.

Ans: Encourage the patient to engage in a moderate amount of exercise. Feedback: The nursing diagnosis of altered peripheral tissue perfusion related to compromised circulation requires interventions that focus on improving circulation. Encouraging the patient to engage in a moderate amount of exercise serves to improve circulation. Elevating his legs and arms above his heart when resting would be passive and fails to promote circulation. Encouraging long periods of sitting or standing would further compromise circulation. The nurse should encourage, not discourage, walking to increase circulation and decrease pain.

A patient with advanced venous insufficiency is confined following orthopedic surgery. How can the nurse best prevent skin breakdown in the patient's lower extremities? A) Ensure that the patient's heels are protected and supported. B) Closely monitor the patient's serum albumin and prealbumin levels. C) Perform gentle massage of the patient's lower legs, as tolerated. D) Perform passive range-of-motion exercises once per shift.

Ans: Ensure that the patient's heels are protected and supported. Feedback: If the patient is on bed rest, it is important to relieve pressure on the heels to prevent pressure ulcerations, since the heels are among the most vulnerable body regions. Monitoring blood work does not directly prevent skin breakdown, even though albumin is related to wound healing. Massage is not normally indicated and may exacerbate skin breakdown. Passive range- of-motion exercises do not directly reduce the risk of skin breakdown.

The nurse is caring for a patient who is admitted to the medical unit for the treatment of a venous ulcer in the area of her lateral malleolus that has been unresponsive to treatment. What is the nurse most likely to find during an assessment of this patient's wound? A) Hemorrhage B) Heavy exudate C) Deep wound bed D) Pale-colored wound bed

Ans: Heavy exudate Feedback: Venous ulcerations in the area of the medial or lateral malleolus (gaiter area) are typically large, superficial, and highly exudative. Venous hypertension causes extravasation of blood, which discolors the area of the wound bed. Bleeding is not normally present.

The nurse caring for a patient with a leg ulcer has finished assessing the patient and is developing a problem list prior to writing a plan of care. What major nursing diagnosis might the care plan include? A) Risk for disuse syndrome B) Ineffective health maintenance C) Sedentary lifestyle D) Imbalanced nutrition: less than body requirements

Ans: Imbalanced nutrition: less than body requirements Feedback: Major nursing diagnoses for the patient with leg ulcers may include imbalanced nutrition: less than body requirements, related to increased need for nutrients that promote wound healing. Risk for disuse syndrome is a state in which an individual is at risk for deterioration of body systems owing to prescribed or unavoidable musculoskeletal inactivity. A leg ulcer will affect activity, but rarely to this degree. Leg ulcers are not necessarily a consequence of ineffective health maintenance or sedentary lifestyle.

While assessing a patient the nurse notes that the patient's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best respond to this assessment finding? A) Assess the patient's use of over-the-counter dietary supplements. B) Implement interventions relevant to arterial narrowing. C) Encourage the patient to increase intake of foods high in vitamin K. D) Adjust the patient's activity level to accommodate decreased coronary output.

Ans: Implement interventions relevant to arterial narrowing. Feedback: ABI is used to assess the degree of stenosis of peripheral arteries. An ABI of less than 1.0 indicates possible claudication of the peripheral arteries. It does not indicate inadequate coronary output. There is no direct indication for changes in vitamin K intake and OTC medications are not likely causative.

You are caring for a patient who is diagnosed with Raynaud's phenomenon. The nurse should plan interventions to address what nursing diagnosis? A) Chronic pain B) Ineffective tissue perfusion C) Impaired skin integrity D) Risk for injury

Ans: Ineffective tissue perfusion Feedback: Raynaud's phenomenon is a form of intermittent arteriolar vasoconstriction resulting in inadequate tissue perfusion. This results in coldness, pain, and pallor of the fingertips or toes. Pain is typically intermittent and acute, not chronic, and skin integrity is rarely at risk. In most cases, the patient is not at a high risk for injury.

A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the patient's left leg is visibly swollen and reddened. What is the nurse's most appropriate action? A) Administer a PRN dose of subcutaneous heparin. B) Inform the physician that the patient has signs and symptoms of VTE. C) Mobilize the patient promptly to dislodge any thrombi in the patient's lower leg. D) Massage the patient's lower leg to temporarily restore venous return.

Ans: Inform the physician that the patient has signs and symptoms of VTE. Feedback: VTE requires prompt medical follow-up. Heparin will not dissolve an established clot. Massaging the patient's leg and mobilizing the patient would be contraindicated because they would dislodge the clot, possibly resulting in a pulmonary embolism.

The nurse is taking a health history of a new patient. The patient reports experiencing pain in his left lower leg and foot when walking. This pain is relieved with rest. The nurse notes that the left lower leg is slightly edematous and is hairless. When planning this patient's subsequent care, the nurse should most likely address what health problem? A) Coronary artery disease (CAD) B) Intermittent claudication C) Arterial embolus D) Raynaud's disease

Ans: Intermittent claudication Feedback: A muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest is experienced by patients with peripheral arterial insufficiency. Referred to as intermittent claudication, this pain is caused by the inability of the arterial system to provide adequate blood flow to the tissues in the face of increased demands for nutrients and oxygen during exercise. The nurse would not suspect the patient has CAD, arterial embolus, or Raynaud's disease; none of these health problems produce this cluster of signs and symptoms.

The nurse is preparing to administer warfarin (Coumadin) to a client with deep vein thrombophlebitis (DVT). Which laboratory value would most clearly indicate that the patient's warfarin is at therapeutic levels? A) Partial thromboplastin time (PTT) within normal reference range B) Prothrombin time (PT) eight to ten times the control C) International normalized ratio (INR) between 2 and 3 D) Hematocrit of 32%

Ans: International normalized ratio (INR) between 2 and 3 Feedback: The INR is most often used to determine if warfarin is at a therapeutic level; an INR of 2 to 3 is considered therapeutic. Warfarin is also considered to be at therapeutic levels when the client's PT is 1.5 to 2 times the control. Higher values indicate increased risk of bleeding and hemorrhage, whereas lower values indicate increased risk of blood clot formation. Heparin, not warfarin, prolongs PTT. Hematocrit does not provide information on the effectiveness of warfarin; however, a falling hematocrit in a client taking warfarin may be a sign of hemorrhage.

The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers. The nurse's assessment should include which of the following components? Select all that apply. A) Location and type of pain B) Apical heart rate C) Bilateral comparison of peripheral pulses D) Comparison of temperature in the patient's legs E) Identification of mobility limitations

Ans: Location and type of pain, Bilateral comparison of peripheral pulses, Comparison of temperature in the patient's legs, Identification of mobility limitations Feedback: A careful nursing history and assessment are important. The extent and type of pain are carefully assessed, as are the appearance and temperature of the skin of both legs. The quality of all peripheral pulses is assessed, and the pulses in both legs are compared. Any limitation of mobility and activity that results from vascular insufficiency is identified. Not likely is there any direct indication for assessment of apical heart rate, although peripheral pulses must be assessed.

The nurse is caring for an acutely ill patient who is on anticoagulant therapy. The patient has a comorbidity of renal insufficiency. How will this patient's renal status affect heparin therapy? A) Heparin is contraindicated in the treatment of this patient. B) Heparin may be administered subcutaneously, but not IV. C) Lower doses of heparin are required for this patient. D) Coumadin will be substituted for heparin.

Ans: Lower doses of heparin are required for this patient. Feedback: If renal insufficiency exists, lower doses of heparin are required. Coumadin cannot be safely and effectively used as a substitute and there is no contraindication for IV administration.

A nurse working in a long-term care facility is performing the admission assessment of a newly admitted, 85-year-old resident. During inspection of the resident's feet, the nurse notes that she appears to have early evidence of gangrene on one of her great toes. The nurse knows that gangrene in the elderly is often the first sign of what? A) Chronic venous insufficiency B) Raynaud's phenomenon C) VTE D) PAD

Ans: PAD Feedback: In elderly people, symptoms of PAD may be more pronounced than in younger people. In elderly patients who are inactive, gangrene may be the first sign of disease. Venous insufficiency does not normally manifest with gangrene. Similarly, VTE and Raynaud's phenomenon do not cause the ischemia that underlies gangrene.

The nurse is caring for a patient with a large venous leg ulcer. What intervention should the nurse implement to promote healing and prevent infection? A) Provide a high-calorie, high-protein diet. B) Apply a clean occlusive dressing once daily and whenever soiled. C) Irrigate the wound with hydrogen peroxide once daily. D) Apply an antibiotic ointment on the surrounding skin with each dressing change.

Ans: Provide a high-calorie, high-protein diet. Feedback: Wound healing is highly dependent on adequate nutrition. The diet should be sufficiently high in calories and protein. Antibiotic ointments are not normally used on the skin surrounding a leg ulcer and occlusive dressings can exacerbate impaired blood flow. Hydrogen peroxide is not normally used because it can damage granulation tissue.

A nurse is closely monitoring a patient who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the patient's aneurysm? A) Sudden increase in blood pressure and a decrease in heart rate B) Cessation of pulsating in an aneurysm that has previously been pulsating visibly C) Sudden onset of severe back or abdominal pain D) New onset of hemoptysis

Ans: Sudden onset of severe back or abdominal pain Feedback: Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Impending rupture is not typically signaled by increased blood pressure, bradycardia, cessation of pulsing, or hemoptysis.

The nurse is assessing a woman who is pregnant at 27 weeks' gestation. The patient is concerned about the recent emergence of varicose veins on the backs of her calves. What is the nurse's best response? A) Facilitate a referral to a vascular surgeon. B) Assess the patient's ankle-brachial index (ABI) and perform Doppler ultrasound testing. C) Encourage the patient to increase her activity level. D) Teach the patient that circulatory changes during pregnancy frequently cause varicose veins.

Ans: Teach the patient that circulatory changes during pregnancy frequently cause varicose veins. Feedback: Pregnancy may cause varicosities because of hormonal effects related to decreased venous outflow, increased pressure by the gravid uterus, and increased blood volume. In most cases, no intervention or referral is necessary. This finding is not an indication for ABI assessment and increased activity will not likely resolve the problem.

A nurse is reviewing the physiological factors that affect a patient's cardiovascular health and tissue oxygenation. What is the systemic arteriovenous oxygen difference? A) The average amount of oxygen removed by each organ in the body B) The amount of oxygen removed from the blood by the heart C) The amount of oxygen returning to the lungs via the pulmonary artery D) The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood

Ans: The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood Feedback: The average amount of oxygen removed collectively by all of the body tissues is about 25%. This means that the blood in the vena cava contains about 25% less oxygen than aortic blood. This is known as the systemic arteriovenous oxygen difference. The other answers do not apply.

Graduated compression stockings have been prescribed to treat a patient's venous insufficiency. What education should the nurse prioritize when introducing this intervention to the patient? A) The need to take anticoagulants concurrent with using compression stockings B) The need to wear the stockings on a "one day on, one day off" schedule C) The importance of wearing the stockings around the clock to ensure maximum benefit D) The importance of ensuring the stockings are applied evenly with no pressure points

Ans: The importance of ensuring the stockings are applied evenly with no pressure points Feedback: Any type of stocking can inadvertently become a tourniquet if applied incorrectly (i.e., rolled tightly at the top). In such instances, the stockings produce rather than prevent stasis. For ambulatory patients, graduated compression stockings are removed at night and reapplied before the legs are lowered from the bed to the floor in the morning. They are used daily, not on alternating days. Anticoagulants are not always indicated in patients who are using compression stockings.

The nurse is providing care for a patient who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis? A) Numbness and tingling in the distal extremities B) Unequal peripheral pulses between extremities C) Visible clubbing of the fingers and toes D) Reddened extremities with muscle atrophy

Ans: Unequal peripheral pulses between extremities Feedback: PAD assessment may manifest as unequal pulses between extremities, with the affected leg cooler and paler than the unaffected leg. Intermittent claudication is far more common than sensations of numbness and tingling. Clubbing and muscle atrophy are not associated with PAD.

A patient presents to the clinic complaining of the inability to grasp objects with her right hand. The patient's right arm is cool and has a difference in blood pressure of more than 20 mm Hg compared with her left arm. The nurse should expect that the primary care provider may diagnose the woman with what health problem? A) Lymphedema B) Raynaud's phenomenon C) Upper extremity arterial occlusive disease D) Upper extremity VTE

Ans: Upper extremity arterial occlusive disease Feedback: The patient with upper extremity arterial occlusive disease typically complains of arm fatigue and pain with exercise (forearm claudication) and inability to hold or grasp objects (e.g., combing hair, placing objects on shelves above the head) and, occasionally, difficulty driving. Assessment findings include coolness and pallor of the affected extremity, decreased capillary refill, and a difference in arm blood pressures of more than 20 mm Hg. These symptoms are not closely associated with Raynaud's or lymphedema. The upper extremities are rare sites for VTE.

A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the pulse in the patient's left foot. How should the nurse proceed with assessment? A) Have the primary care provider order a CT. B) Apply a tourniquet for 3 to 5 minutes and then reassess. C) Elevate the extremity and attempt to palpate the pulses. D) Use Doppler ultrasound to identify the pulses.

Ans: Use Doppler ultrasound to identify the pulses. Feedback: When pulses cannot be reliably palpated, a hand-held continuous wave (CW) Doppler ultrasound device may be used to hear (insonate) the blood flow in vessels. CT is not normally warranted and the application of a tourniquet poses health risks and will not aid assessment. Elevating the extremity would make palpation more difficult.

The prevention of VTE is an important part of the nursing care of high-risk patients. When providing patient teaching for these high-risk patients, the nurse should advise lifestyle changes, including which of the following? Select all that apply. A) High-protein diet B) Weight loss C) Regular exercise D) Smoking cessation E) Calcium and vitamin D supplementation

Ans: Weight loss, Regular exercise, Smoking cessation Feedback: Patients 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 nurse is caring for a patient with a diagnosis of deep venous thrombosis (DVT). The patient has an order to receive 30 mg enoxaparin (Lovenox). Which injection site should the nurse use to administer this medication safely? A) Buttock, upper outer quadrant B) Abdomen, anterior-lateral aspect C) Back of the arm, 2 inches away from a mole D) Anterolateral thigh, with no scar tissue nearby

B) Enoxaparin (Lovenox) is a low-molecular-weight (LMW) heparin that is given as a deep subcutaneous injection in the right and left anterolateral abdomen. All subcutaneous injections should be given away from scars, lesions, or moles.

A 62-year-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral artery disease (PAD). The patient is a smoker and has a history of gout. What should the nurse focus her teaching on to prevent complications for this patient? A) Gender B) Smoking C) Ethnicity D) Co-morbidities

B) Smoking is the most significant factor for this patient. PAD is a marker of advanced systemic atherosclerosis. Therefore tobacco cessation is essential to reduce PAD progression, CVD events, and mortality. Diabetes mellitus and hyperuricemia are also risk factors. Being male or Hispanic are not risk factors for PAD.

The nurse is caring for a newly admitted patient with vascular insufficiency. The patient has a new order for enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to correctly administer this medication? A) Spread the skin before inserting the needle. B) Leave the air bubble in the prefilled syringe. C) Use the back of the arm as the preferred site. D) Sit the patient at a 30-degree angle before administration.

B) The nurse should not expel the air bubble from the prefilled syringe because it should be injected to clear the needle of medication and avoid leaving medication in the needle track in the tissue.

A patient with varicose veins has been prescribed compression stockings. How should the nurse teach the patient to use these? A) "Try to keep your stockings on 24 hours a day, as much as possible." B) "While you're still lying in bed in the morning, put on your stockings." C) "Dangle your feet at your bedside for 5 minutes before putting on your stockings." D) "Your stockings will be most effective if you can remove them for a few minutes several times a day."

B) The patient with varicose veins should apply stockings in bed, before rising in the morning. Stockings should not be worn continuously, but they should not be removed several times daily. Dangling at the bedside prior to application is likely to decrease their effectiveness.

A patient was just diagnosed with acute arterial ischemia in the left leg secondary to atrial fibrillation. Which early clinical manifestation must be reported to the physician immediately to save the patient's limb? A) Paralysis B) Paresthesia D) Crampiness E) Referred pain

B) The physician must be notified immediately if any of the six Ps of acute arterial ischemia occur to prevent ischemia from quickly progressing to tissue necrosis and gangrene. The six Ps are paresthesia, pain, pallor, pulselessness, and poikilothermia, with paralysis being a very late sign indicating the death of nerves to the extremity. Crampy leg sensation is more common with varicose veins. The pain is not referred.

The patient had aortic aneurysm repair. What priority nursing action will the nurse use to maintain graft patency? Assess output for renal dysfunction. Use IV fluids to maintain adequate BP. Use oral antihypertensives to maintain cardiac output. Maintain a low BP to prevent pressure on surgical site

B) The priority is to maintain an adequate BP (determined by the surgeon) to maintain graft patency. A prolonged low BP may result in graft thrombosis, and hypertension may cause undue stress on arterial anastomoses resulting in leakage of blood or rupture at the suture lines, which is when IV antihypertensives may be used. Renal output will be assessed when the aneurysm repair is above the renal arteries to assess graft patency, not maintain it.

A female patient with critical limb ischemia has had peripheral artery bypass surgery to improve her circulation. What care should the nurse provide on postoperative day 1? A) Keep the patient on bed rest. B) Assist the patient with walking several times. C) Have the patient sit in the chair several times. D) Place the patient on her side with knees flexed.

B) To avoid blockage of the graft or stent, the patient should walk several times on postoperative day 1 and subsequent days. Having the patient's knees flexed for sitting in a chair or in bed increase the risk of venous thrombosis and may place stress on the suture lines.

When caring for a client with an 8-cm abdominal aortic aneurysm (AAA), the nurse recognizes that which problem must be addressed immediately to prevent rupture? A. Heart rate 52 B. Blood pressure 192/102 C. Report of constipation D. Anxiety

Blood pressure 192/102

The nurse would determine that a postoperative patient is not receiving the beneficial effects of enoxaparin (Lovenox) after noting what during a routine shift assessment? A) Generalized weakness and fatigue B) Crackles bilaterally in the lung bases C) Pain and swelling in lower extremity D) Abdominal pain with decreased bowel sounds

C) Enoxaparin is a low-molecular-weight heparin used to prevent the development of deep vein thromboses (DVTs) in the postoperative period. Pain and swelling in the lower extremity can indicate development of DVT and therefore may signal ineffective medication therapy.

A postoperative patient asks the nurse why the physician ordered daily administration of enoxaparin (Lovenox). Which reply by the nurse is most appropriate? A) "This medication will help prevent breathing problems after surgery, such as pneumonia." B) "This medication will help lower your blood pressure to a safer level, which is very important after surgery." C) "This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal." D) "This medication is a narcotic pain medication that will help take away any muscle aches caused by positioning on the operating room table."

C) Enoxaparin is an anticoagulant that is used to prevent DVTs postoperatively. All other explanations/options do not describe the action/purpose of enoxaparin.

The nurse is caring for a preoperative patient who has an order for vitamin K by subcutaneous injection. The nurse should verify that which laboratory study is abnormal before administering the dose? A) Hematocrit (Hct) B) Hemoglobin (Hgb) C) Prothrombin time (PT) D) Partial thromboplastin time (PTT)

C) Vitamin K counteracts hypoprothrombinemia and/or reverses the effects of warfarin (Coumadin) and thus decreases the risk of bleeding. High values for either the prothrombin time (PT) or the international normalized ratio (INR) demonstrates the need for this medication.

The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed? A) Decreased cardiac output B) Increased blood pressure C) Cerebral or pulmonary emboli D) Excessive bleeding from incision or IV sites

C) Warfarin is an anticoagulant that is used to prevent thrombi from forming on the walls of the atria during atrial fibrillation. Once the medication is terminated, thrombi could again form. If one or more thrombi detach from the atrial wall, they could travel as cerebral emboli from the left atrium or pulmonary emboli from the right atrium.

inflow disease

Chronic peripheral arterial disease with obstruction at or above the common iliac artery, abdominal aorta, or profunda femoris artery. The patient experiences discomfort in the lower back, buttocks, or thighs after walking a certain distance. The pain usually subsides with rest.

Outflow disease

Chronic peripheral arterial disease with obstruction at or below the superficial femoral or popliteal artery. The patient experiences burning or cramping in the calves, ankles, feet, and toes after walking a certain distance; the pain usually subsides with rest.

collateral circulation

Circulation that provides blood to an area with altered tissue perfusion through smaller vessels that develop and compensate for the occluded vessels.

When caring for a client who has received recombinant tissue plasminogen activator (t-PA), for a large deep vein thrombosis (DVT), the nurse would be most concerned if the client developed which of these? A. Small amount of blood at the IV insertion site B. Heavy menstrual bleeding C. +1 pitting edema of the affected extremity D. Client stating that the year is 1967

Client stating that the year is 1967

The nurse suspects that the client has developed an acute arterial occlusion of the right lower extremity based on which of the following? Select all that apply. A. Hypertension B. Tachycardia C. Bounding right pedal pulses D. Cold right foot E. Numbness and tingling of right foot F. Mottling of right foot and lower leg

Cold right foot Numbness and tingling of right foot Mottling of right foot and lower leg

When administering furosemide (Lasix) to a client who states she does not like bananas or orange juice, the nurse recommends that the client try which intervention to maintain potassium levels? A. Increase red meat in the diet. B. Consume melons and baked potato. C. Add several portions of dairy products each day. D. Try replacing your usual breakfast with oatmeal or cream of wheat.

Consume melons and baked potato.

What is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)? A) Application of topical antibiotics to venous ulcers B) Maintaining the patient's legs in a dependent position C) Administration of oral and/or subcutaneous anticoagulants D) Teaching the patient the correct use of compression stockings

D) CVI requires conscientious and consistent application of compression stockings. Anticoagulants are not necessarily indicated and antibiotics, if required, are typically oral or IV, not topical. The patient should avoid prolonged positioning with the limb in a dependent position.

The patient reports tenderness when she touches her leg over a vein. The nurse assesses warmth and a palpable cord in the area. The nurse knows the patient needs treatment to prevent which sequelae? A) Pulmonary embolism Pulmonary hypertension Post-thrombotic syndrome Venous thromboembolism

D) The clinical manifestations are characteristic of a superficial vein thrombosis. If untreated, the clot may extend to deeper veins, and venous thromboembolism may occur. Pulmonary embolism, pulmonary hypertension, and post-thrombotic syndrome are the sequelae of venous thromboembolism.

A male patient was admitted for a possible ruptured aortic aneurysm, but had no back pain. Ten minutes later his assessment includes the following: sinus tachycardia at 138, BP palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret this assessment about the patient's aneurysm? A) Tamponade will soon occur. B) The renal arteries are involved. C) Perfusion to the legs is impaired. D) He is bleeding into the abdomen.

D) The lack of back pain indicates the patient is most likely exsanguinating into the abdominal space, and the bleeding is likely to continue without surgical repair. A blockade of the blood flow will not occur in the abdominal space as it would in the retroperitoneal space where surrounding anatomic structures may control the bleeding. The lack of urine output does not indicate renal artery involvement, but that the bleeding is occurring above the renal arteries, which decreases the blood flow to the kidneys. There is no assessment data indicating decreased perfusion to the legs.

The nurse is preparing to administer a scheduled dose of enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to administer this medication correctly? A) Remove the air bubble in the prefilled syringe. B) Aspirate before injection to prevent IV administration. C) Rub the injection site after administration to enhance absorption. D) Pinch the skin between the thumb and forefinger before inserting the needle.

D) The nurse should gather together or "bunch up" the skin between the thumb and the forefinger before inserting the needle into the subcutaneous tissue. The nurse should not remove the air bubble in the prefilled syringe, aspirate, nor rub the site after injection.

The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT). The patient now needs to undergo surgery for appendicitis. The nurse is reviewing the laboratory results for this patient before administering an ordered dose of vitamin K. The nurse determines that the medication is both safe to give and is most needed when the international normalized ratio (INR) is which result? A) 1.0 B) 1.2 C) 1.6 D) 2.2

D) Vitamin K is the antidote to warfarin (Coumadin), which the patient has most likely been taking before admission for treatment of DVT. Warfarin is an anticoagulant that impairs the ability of the blood to clot. Therefore it is necessary to give vitamin K before surgery to reduce the risk of hemorrhage. The largest value of the INR indicates the greatest impairment of clotting ability, making 2.2 the correct selection.

The nurse is caring for a client who is being treated for hypertensive emergency. Which medication prescribed for the client should the nurse question? A. Enalapril (Vasotec) B. Sodium nitroprusside (Nipride) C. Dopamine (Intropin) D. Clevidipine (butyrate)

Dopamine (Intropin)

hypertriglyceridemia

Elevated levels (150 mg/dL or above) of triglyceride in the blood.

Nonsurgical Management used to increase arterial flow to the affected leg(s)

Exercise, positioning, promoting vasodilation, drug therapy, and invasive nonsurgical procedures

Etiology of Essential or Primary Hypertension

Family history of hypertension African-American ethnicity Hyperlipidemia Smoking Older than 60 years or postmenopausal Excessive sodium and caffeine intake Overweight/obesity Physical inactivity Excessive alcohol intake Low potassium, calcium, or magnesium intake Excessive and continuous stress

The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the last appointment. Which actions by the client indicate that teaching has been effective? Select all that apply. A. Has maintained a low-sodium, no-added-salt diet B. Has lost 3 pounds since last seen in the clinic C. Cooks food in palm oil to save money D. Exercises once weekly E. Has cut down on caffeine

Has maintained a low-sodium, no-added-salt diet Has lost 3 pounds since last seen in the clinic Has cut down on caffeine

Etiology of Secondary Hypertension

Kidney disease Primary aldosteronism Pheochromocytoma Cushing's disease Coarctation of the aorta Brain tumors Encephalitis Pregnancy Drugs: Estrogen (e.g., oral contraceptives) Glucocorticoids Mineralocorticoids Sympathomimetics

The nurse is providing community education about prevention of atherosclerosis-related diseases. Which risk factors should the nurse include in the presentation? Select all that apply. A. LDL cholesterol of 160 mg B. Smoking C. Aspirin (ASA) consumption D. Type 2 diabetes E. Vegetarian diet

LDL cholesterol of 160 mg Smoking Type 2 diabetes

Risk factors for atherosclerosis

Low HDL-C, High LDL-C, Increased triglycerides, Genetic predisposition, Diabetes mellitus, Obesity, Sedentary lifestyle, Smoking, Stress, African-American or Hispanic ethnicity, Older adult

The nurse is caring for a client with an abdominal aortic aneurysm (AAA). Which finding in the history does the nurse recognize as a risk factor for aneurysm formation? A. Peptic ulcer disease B. Deep vein thrombosis (DVT) C. Osteoarthritis D. Marfan syndrome

Marfan syndrome

Those with acute arterial insufficiency often present with the "six P's" of ischemia:

Pain Pallor Pulselessness Paresthesia Paralysis Poikilothermy (coolness)

The client with peripheral arterial occlusive disease has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure? A. Ankle-brachial index (ABI) B. Dye allergy C. Pedal pulses D. Gag reflex

Pedal pulses

The client is receiving unfractionated heparin by infusion. Of which finding should the nurse notify the provider? A. Partial thromboplastin time (PTT) 60 seconds B. Platelets 32,000 C. White blood cells (WBCs) 11,000 D. Hemoglobin 12.2 g/dL

Platelets 32,000

thrombectomy

Removal of a clot (thrombus) from a blood vessel.

The professional nurse and the nursing student are caring for a group of clients with hypertension. Which of these problems identified by the nursing student correctly identifies the client at risk for secondary hypertension? A. Psychiatric disturbance B. High sodium intake C. Physical inactivity D. Renal failure

Renal failure

The nurse is caring for a client with peripheral arterial occlusive disease (PAD). For which symptoms should the nurse assess? A. Reproducible leg pain with exercise B. Unilateral swelling of affected leg C. Decreased pain when legs are elevated D. Pulse oximetry reading of 90%

Reproducible leg pain with exercise

What is the most frequent complication of aneurysms and is life threatening ?

Rupture because abrupt and massive hemorrhagic shock results. Thrombi within the wall of an aneurysm can also be the source of emboli in distal arteries below the aneurysm.

Which symptom reported by the client who has had a total hip replacement requires emergency action? A. Localized swelling of one of the lower extremities B. Positive Homans' sign C. Shortness of breath and chest pain D. Tenderness and redness at the IV site

Shortness of breath and chest pain

Which vascular assessment technique by the student nurse requires intervention by the supervising nurse? A. Measuring capillary refill in the fingertips B. Assessing pedal pulses by Doppler C. Measuring blood pressure in both arms D. Simultaneously palpating the bilateral carotids

Simultaneously palpating the bilateral carotids

A client has undergone an embolectomy for acute arterial occlusion after creation of a lower arm A-V fistula for dialysis. Which finding should the nurse report to the provider immediately? A. Swelling and tenseness in the affected area B. Incisional pain and tenderness at the surgical site C. Pink, mobile fingers D. Client who has order for heparin infusion

Swelling and tenseness in the affected area

bruit

Swishing sound in the larger arteries (carotid, aortic, femoral, and popliteal) that can be heard with a stethoscope or Doppler probe; may indicate narrowing of the artery and is usually associated with atherosclerotic disease.

Prehypertension

Systolic 120-139 mm Hg or diastolic 80-89 mm Hg

Stage 1: Hypertension

Systolic 140-159 mm Hg or diastolic 90-99 mm Hg

Normal Blood Pressure

Systolic <120 mm Hg and diastolic <80 mm Hg

Stage 2: Hypertension

Systolic ≥160 mm Hg or diastolic ≥100 mm Hg

The client with hypertension is started on verapamil (Isoptin). What teaching does the nurse provide for this client? A. Encourages foods high in potassium B. Monitors for irregular pulse C. Monitors for muscle cramping D. Teaches the client to avoid grapefruit juice

Teaches the client to avoid grapefruit juice

Which of these clients who have just arrived in the emergency department should the nurse classify as emergent and needing immediate medical evaluation? A. The 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness B. The 64-year-old with chronic venous ulcers who has a temperature of 100.1° F (37.8° C) C. The 69-year-old with a 40-pack-year cigarette history who is reporting foot numbness D. The 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic

The 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic

All of these client assignments have been made by the charge nurse. Which assignment would you question? A. The RN with 3 years of experience caring for a client with a pulmonary embolism (PE) who is receiving heparin therapy B. The LPN/LVN with 5 years of experience caring for a client with leg ulcers who is awaiting nursing home placement C. The RN with 8 years of experience caring for a client with peripheral arterial disease (PAD) and a total cholesterol of 390 D. The LPN/LVN with 20 years of experience caring for a client with a headache whose blood pressure is 210/150

The LPN/LVN with 20 years of experience caring for a client with a headache whose blood pressure is 210/150

Which of the following is essential to report to the provider when caring for a client with Raynaud's phenomenon? A. Nifedipine (Procardia) administration caused the blood pressure to change from 134/76 to 110/68. B. The client's extremity became white, then red temporarily. C. The affected extremity becomes purple and cold. D. The client states that the digits are painful when they are white.

The affected extremity becomes purple and cold.

heparin-induced thrombocytopenia and thrombosis (HIT)

The aggregation of platelets into "white clots" that can cause thrombosis, usually in the form of an acute arterial occlusion; occurs with heparin administration; also called "white clot syndrome."

Four control systems play a major role in maintaining blood pressure:

The arterial baroreceptor system Regulation of body fluid volume The renin-angiotensin/aldosterone system Vascular autoregulation.

The nurse is assigned to the following group of clients. Which of these clients should be assessed first? A. The client who had percutaneous transluminal angioplasty of the right femoral artery 30 minutes ago B. The client admitted with hypertensive crisis who has a nitroprusside (Nipride) drip and blood pressure (BP) of 149/80 C. The client with peripheral vascular disease who has a left leg ulcer draining purulent yellow fluid D. The client who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot

The client who had percutaneous transluminal angioplasty of the right femoral artery 30 minutes ago

Virchow's triad

The occurrence of stasis of blood flow, endothelial injury, or hypercoagulability; often associated with thrombus formation.

endovascular stent graft

The repair of an abdominal aortic aneurysm using a stent made of flexible material; the stent is inserted through a skin incision into the femoral artery by way of a catheter-based system.

acute arterial occlusion

The sudden blockage of an artery, typically in the lower extremity, in the patient with chronic peripheral arterial disease.

arterial revascularization

The surgical procedure most commonly used to increase arterial blood flow in the affected limb of a patient with peripheral arterial disease.

The nurse caring for a client who has had AAA repair would be most alarmed by which finding? A. Urine output of 20 mL over 2 hours B. Blood pressure of 106/58 C. Absent bowel sounds D. +3 pedal pulses

Urine output of 20 mL over 2 hours

The nurse teaches a client who has had a myocardial infarction (MI) which information regarding diet? A. Less than 30% of the daily caloric intake should be derived from proteins. B. Use canola oil rather than palm or coconut oil. C. Consume 10 mg fiber daily. D. Work toward lowering your HDL cholesterol levels.

Use canola oil rather than palm or coconut oil.

Which teaching should the nurse include for a client with peripheral arterial disease (PAD)? A. Elevate your legs above heart level to prevent swelling. B. Inspect your legs daily for brownish discoloration around the ankle. C. Walk to the point of leg pain, then rest, resuming when pain stops. D. Apply a heating pad to the legs if they feel cold.

Walk to the point of leg pain, then rest, resuming when pain stops.

The most common side effect of ACE inhibitors is

a nagging, dry cough. Teach patients to report this problem to their health care provider as soon as possible. If a cough develops, the drug is discontinued.

The most common surgical procedure for AAA has traditionally been

a resection or repair (aneurysmectomy)

Aortic dissection is thought to be caused by

a sudden tear in the aortic intima, opening the way for blood to enter the aortic wall. Degeneration of the aortic media may be the primary cause for this condition, with hypertension being an important contributing factor.

Atherosclerosis,

a type of arteriosclerosis, involves the formation of plaque within the arterial wall and is the leading risk factor for cardiovascular disease.

Assess patients with a known or suspected abdominal aortic aneurysm (AAA) for

abdominal, flank, or back pain. Pain is usually described as steady with a gnawing quality, unaffected by movement, and lasting for hours or days. A pulsation in the upper abdomen slightly to the left of the midline between the xyphoid process and the umbilicus may be present. A detectable aneurysm is at least 5 cm in diameter. Auscultate for a bruit over the mass, but avoid palpating the mass because it may be tender and there is risk for rupture! If expansion and impending rupture of an AAA are suspected, assess for severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs.

Abdominal aortic aneurysms (AAAs)

account for most aneurysms, are commonly asymptomatic, and frequently rupture. Most of these are located between the renal arteries and the aortic bifurcation (dividing area).

Angiotensin II receptor antagonists,

also called angiotensin II receptor blockers (ARBs) or the -sartan drugs, make up a group of drugs that selectively block the binding of angiotensin II to receptor sites in the vascular smooth muscle and adrenal tissues by competing directly with angiotensin II but not inhibiting ACE.

Angiotensin-converting enzyme (ACE) inhibitors,

also known as the "pril" drugs, are also used as single or combination agents in the treatment of hypertension. These drugs block the action of the angiotensin-converting enzyme as it attempts to convert angiotensin I to angiotensin II, one of the most powerful vasoconstrictors in the body. This action also decreases sodium and water retention and lowers peripheral vascular resistance, both of which lower blood pressure.

A decrease in intensity or a complete loss of a pulse in a patient with atherosclerosis may indicate .

an arterial occlusion (blockage).

familial hyperlipidemia,

an elevation of serum lipid levels. In these people, the liver makes excessive cholesterol and other fats. However, some people with hereditary atherosclerosis have a normal blood cholesterol level.

saccular

an outpouching affecting only a distinct portion of the artery

Impedance plethysmography

assesses venous outflow and can detect most DVTs that are located above the popliteal vein. It is not helpful in locating clots in the calf and is less sensitive than Doppler studies.

When a thoracic aortic aneurysm is suspected, assess for

back pain and manifestations of compression of the aneurysm on adjacent structures. Signs include shortness of breath, hoarseness, and difficulty swallowing. TAAs are not often detected by physical assessment, but occasionally a mass may be visible above the suprasternal notch. Assess the patient with suspected rupture of a thoracic aneurysm for sudden and excruciating back or chest pain. Hypovolemic shock also occurs with TAA.

The classic signs and symptoms of DVT are

calf or groin tenderness and pain and sudden onset of unilateral swelling of the leg.

Central alpha agonists act on the

central nervous system, preventing reuptake of norepinephrine and resulting in lower peripheral vascular resistance and blood pressure. Side effects include sedation, postural hypotension, and impotence.

Monitor the patency of the graft by

checking the extremity every 15 minutes for the first hour and then hourly for changes in color, temperature, and pulse intensity. Compare the operative leg with the unaffected one. If the operative leg feels cold; becomes pale, ashen, or cyanotic; or has a decreased or absent pulse, contact the surgeon immediately!

Statins reduce

cholesterol synthesis in the liver and increase clearance of LDL-C from the blood.

fusiform

diffuse dilation affecting the entire circumference of the artery

Alpha-adrenergic antagonists,

dilate the arterioles and veins. These drugs can lower blood pressure quickly, but their use is limited because of frequent and bothersome side effects.

Teach patients about common side effects of beta blockers, including

fatigue, weakness, depression, and sexual dysfunction.

For patients with chronic PAD, prescribed drugs include

hemorheologic and antiplatelet agents.

Assess _______________for for patients taking potassium-sparing diuretics, such as spironolactone.

hyperkalemia (high potassium level) Like hypokalemia, an increased potassium level can also cause weakness and irregular pulse.

Beta blockers are the drug of choice for .

hypertensive patients with ischemic heart disease (IHD) because the heart is the most common target of end-organ damage with hypertension.

Patients with diabetes who take beta blockers may not have the usual manifestations of

hypoglycemia because the sympathetic nervous system is blocked.

The most frequent side effect associated with thiazide and loop diuretics is

hypokalemia (low potassium level). Monitor serum potassium levels, and assess for irregular pulse and muscle weakness, which may indicate hypokalemia.

Signs of rupturing AAA include

hypotension, diaphoresis, decreased level of consciousness, oliguria (scant urine output), loss of pulses distal to the rupture, and dysrhythmias. Retroperitoneal hemorrhage is manifested by hematomas in the flanks (lower back). Rupture into the abdominal cavity causes abdominal distention.

Beta-adrenergic blockers,

identified by the ending -olol, are categorized as cardioselective (working only on the cardiovascular system) and non-cardioselective. Cardioselective beta blockers, affecting only beta-1 receptors, may be prescribed to lower blood pressure by blocking beta receptors in the heart and peripheral vessels. By blocking these receptors, the drugs decrease heart rate and myocardial contractility.

Peripheral vascular disease (PVD)

includes disorders that change the natural flow of blood through the arteries and veins of the peripheral circulation. It affects the legs much more frequently than the arms.

The most serious complication from thrombolytic therapy is

intracerebral bleeding. Closely monitor patients for signs and symptoms of increasing intracranial pressure. A decreased level of consciousness (LOC) is the earliest indicator of this complication. Assess for other neurologic changes and report them immediately to the physician.

Orthostatic hypotension

is a decrease in blood pressure (20 mm Hg systolic and/or 10 mm Hg diastolic) when the patient changes position from lying to sitting.

A D-dimer test

is a global marker of coagulation activation and measures fibrin degradation products produced from fibrinolysis (clot breakdown). The test is used for the diagnosis of DVT when the patient has few clinical signs and stratifies patients into a high-risk category for reoccurrence. Useful as an adjunct to noninvasive testing, a negative D-dimer test can exclude a DVT without an ultrasound.

Graft occlusion (blockage)

is a postoperative emergency that can occur within the first 24 hours after arterial revascularization. Monitor the patient for and report severe continuous and aching pain, which may be the first indicator of postoperative graft occlusion and ischemia. Many people experience a throbbing pain caused by the increased blood flow to the extremity

Malignant hypertension

is a severe type of elevated blood pressure that rapidly progresses. A person with this health problem usually has symptoms such as morning headaches, blurred vision, and dyspnea and/or symptoms of uremia

hypertension

is a systolic blood pressure at or above 140 mm Hg and/or a diastolic blood pressure at or above 90 mm Hg in people who do not have diabetes mellitus.

Arteriosclerosis

is a thickening, or hardening, of the arterial wall that is often associated with aging.

Buerger's disease (thromboangiitis obliterans)

is an uncommon occlusive disease of the arteries and veins in the distal portion of the upper and lower extremities. The disease often extends into the tissues around the vessels, resulting in fibrosis and scarring that bind the artery, vein, and nerve firmly together.

Renin inhibitors are effective for

mild to moderate hypertension. Renin is an enzyme produced in the kidneys that causes vasoconstriction, increases peripheral resistance, and increases cardiac output. The result is an increase in blood pressure. Renin inhibitors prevent renin from producing this action.

ARBs are excellent options for patients who

report a nagging cough associated with ACE inhibitors. In addition, these drugs do not require initial adjustment of the dose for older adults or for any patient with renal impairment.

After TAA repair, patients are especially likely to develop

respiratory distress from atelectasis or pneumonia. This problem occurs as a result of both CPB and incisional discomfort. Both atelectasis and pneumonia may cause shallow breathing and poor cough effort. These patients are often mechanically ventilated at least overnight after surgery.

A major priority for nursing care after an AAA surgical repair is to assess for

signs of graft occlusion or rupture. Assess vital signs and circulation every 15 minutes for the first hour and then hourly, with assessment of pulses distal to the graft site (including the posterior tibial and dorsalis pedis pulses).

PAD is a result of

systemic atherosclerosis.

When dissecting aneurysms occur,

the aneurysm enlarges, blood is lost, and blood flow to organs is diminished.

In true aneurysms,

the arterial wall is weakened by congenital or acquired problems.

Statin drugs are discontinued if

the patient has muscle cramping or elevated liver enzyme levels. Some patients also report abdominal bloating, flatulence, diarrhea, and/or constipation as side effect of these drugs.

Compartment syndrome occurs when

tissue pressure within a confined body space becomes elevated and restricts blood flow. The resulting ischemia can lead to tissue damage and eventually tissue death. Assess the motor and sensory function of the affected extremity. Monitor for increasing pain, swelling, and tenseness.

The priority for nursing care following a PTA or atherectomy is

to observe for bleeding at the arterial puncture site, which is usually sealed with special collagen plugs. Monitor for manifestations of impending hypovolemic shock, including a decrease in blood pressure, increased pulse rate, and decreased urinary output. Perform frequent checks of the distal pulses in both legs to ensure adequate perfusion and oxygenation.

Raynaud's phenomenon is caused by

vasospasm of the arterioles and arteries of the upper and lower extremities, usually unilaterally. Raynaud's disease occurs bilaterally.

Calcium channel blockers such as

verapamil hydrochloride (Calan, Nu-Verap ) and amlodipine (Norvasc) lower blood pressure by interfering with the transmembrane flux of calcium ions. This results in vasodilation, which decreases blood pressure. These drugs also block SA and AV node conduction, resulting in a decreased heart rate.

False aneurysms occur as a result of

vessel injury or trauma to all three layers of the arterial wall.

Report signs of graft occlusion or rupture, including:

• Changes in pulses • Cool to cold extremities below the graft • White or blue extremities or flanks • Severe pain • Abdominal distention • Decreased urine output

Complications for stent repair include:

• Conversion to open surgical repair • Bleeding • Aneurysm rupture • Peripheral embolization • Misplacement of the stent graft

The expected outcomes for emergency care for a patient with an aortic dissection are:

• Elimination of pain • Reduction of systolic blood pressure to 100 to 120 mm Hg • Decrease in the velocity of left ventricular ejection

Assess for and help prevent postoperative complications that can occur after a thoracic aneurysm repair. Complications include:

• Hemorrhage • Ischemic colitis • Cerebral and spinal cord ischemia (causing paraplegia) • Respiratory distress • Infection • Cardiac dysrhythmias

Commonly used alternatives to unfractionated heparin include:

• Low-molecular weight heparin (e.g., enoxaparin [Lovenox]) (drug class of choice after orthopedic surgery) • Selective factor Xa inhibitors (e.g., fondaparinux [Arixtra]) • Warfarin (Coumadin, Warfilone )

Chronic Peripheral Arterial Disease Stage II: Claudication

• Muscle pain, cramping, or burning occurs with exercise and is relieved with rest. • Symptoms are reproducible with exercise.

Complications of AAA repair include:

• Myocardial infarction • Graft occlusion or rupture causing hemorrhage • Hypovolemia and/or renal failure • Respiratory distress • Paralytic ileus

Chronic Peripheral Arterial Disease Stage I: Asymptomatic

• No claudication is present. • Bruit or aneurysm may be present. • Pedal pulses are decreased or absent.

Chronic Peripheral Arterial Disease Stage III: Rest Pain

• Pain while resting commonly awakens the patient at night. • Pain is described as numbness, burning, toothache-type pain. • Pain usually occurs in the distal portion of the extremity (toes, arch, forefoot, or heel), rarely in the calf or the ankle. • Pain is relieved by placing the extremity in a dependent position.

Emergency Care of Patients with Hypertensive Urgency or Crisis: Intervene

• Place patient in a semi-Fowler's position. • Administer oxygen. • Start IV of 0.9% normal saline (NS) solution slowly to prevent fluid overload (which would increase blood pressure). • Administer IV nitroprusside (Nitropress), nicardipine (Cardene IV), or other infusion drug as prescribed (for nitroprusside, cover infusion bag to prevent drug breakdown by light); when stable, switch to oral antihypertensive drug. • Monitor BP every 5 to 15 minutes until the diastolic pressure is below 90 and not less than 75; then monitor BP every 30 minutes to ensure that BP is not lowered too quickly. • Observe for neurologic or cardiovascular complications, such as seizures; numbness, weakness, or tingling of extremities; dysrhythmias; or chest pain (possible indicators of target organ damage).

Emergency Care of Patients with Hypertensive Urgency or Crisis: Assess

• Severe headache • Extremely high blood pressure (BP) • Dizziness • Blurred vision • Shortness of breath • Epistaxis (nosebleed) • Severe anxiety

Three health problems alter the blood flow in veins:

• Thrombus formation (venous thrombosis) can lead to pulmonary embolism (PE), a life-threatening complication. Venous thromboembolism (VTE) is the current term that includes both deep vein thrombosis and PE. • Defective valves lead to venous insufficiency and varicose veins, which are not life threatening but are problematic. • Skeletal muscles do not contract to help pump blood in the veins. This problem can occur when weight-bearing is limited or muscle tone decreases.

Chronic Peripheral Arterial Disease Stage IV: Necrosis/Gangrene

• Ulcers and blackened tissue occur on the toes, the forefoot, and the heel. • Distinctive gangrenous odor is present.