VTE & CVI

The nurse assesses two new wounds located on a client's right and left buttocks. Which intervention for wound management would the nurse employ? Select all that apply.

Evaluate the client's level of pain, using a numeric value pain scale. Ask the client whether the wound bed or surrounding skin itches. Palpate the client's skin for moisture, temperature, and texture. Measure and assess the client's wound bed, size, edges, and margins.

A nurse has been assigned to care for a client with newly diagnosed insulin-dependent diabetes mellitus. When teaching the client proper injection techniques, which statement will the nurse use to promote emotional readiness in the client?

"Can you teach me what I just showed you?"

Which statement by the client indicates the client's experiential readiness to learn?

"Do you have a video about my disease? I don't like to read."

Which observation regarding ulcer formation on the client's lower extremity indicates to the nurse that the ulcer is a result of venous insufficiency?

Large and superficial

The nurse is preparing a client for surgery. The nurse would notify the surgeon if the client made which of the following statements? Select all that apply.

"I took my Coumadin as usual last evening." "I took two aspirins for joint pain this morning."

The nurse is administering anticoagulant therapy with heparin. What International Normalized Ratio (INR) would the nurse know is within therapeutic range?

2.0 to 2.5

The nurse determines that a patient is at risk for the development of thrombophlebitis. What interventions can the nurse provide to prevent this? (Select all that apply.)

Assisting the patient with leg exercises Encouraging early ambulation Avoiding placement of pillows or blanket rolls under the patient's knees

The nurse is caring for a client diagnosed with unstable angina who is receiving IV heparin. The client requires bleeding precautions. Bleeding precautions include which measure?

Avoid continuous BP monitoring

The nurse is assessing a patient with suspected acute venous insufficiency. What clinical manifestations would indicate this condition to the nurse? (Select all that apply.)

Cool and cyanotic skin Sharp pain that may be relieved by the elevation of the extremity Full superficial veins

When assessing a postsurgical client's risk for deep vein thrombosis, the nurse should prioritize what assessment parameter?

Hydration status

A patient is being treated for chronic venous stasis ulcers of the lower extremities. What medication does the nurse understand will increase peripheral blood flow by decreasing the viscosity of blood and assist with the healing of the ulcers?

Pentoxifylline (Trental)

The nurse is preparing a teaching tool about the development of a venous thromboembolism. Which information about Virchow triad will the nurse include? Select all that apply.

Venous stasis Endothelial damage Altered coagulation

A client with a history of aching leg pain seeks medical attention for the development of a leg wound. Which assessment findings indicate to the nurse that the client is experiencing a venous ulcer? Select all that apply.

Wound is superficial Wound has an irregular border Thick, tough skin around the ankles Darkened skin around the lower extremities

A client with advanced cirrhosis has a prothrombin time (PT) of 15 seconds, compared with a control time of 11 seconds. The nurse expects to administer:

phytonadione (Mephyton).

Beginning warfarin concomitantly with heparin can provide a stable INR by which day of heparin treatment?

5

The nurse is evaluating the expected outcomes following thrombolytic therapy for a right leg deep vein thrombosis. Which of the following findings confirms a positive outcome? Select all that apply.

Client denies pain Right extremity pink Right extremity comparable in size to left No bleeding or bruising noted

Which component of the nursing process deals with the identification of client problems?

Diagnosis

While receiving a heparin infusion to treat deep vein thrombosis, a client reports bleeding in the gums when brushing teeth. What should the nurse do first?

Notify the healthcare provider

The nurse is preparing discharge teaching for a client with venous insufficiency. Which information will the nurse include in the instructions? Select all that apply.

Sleep with the foot of the bed elevated 6 inches. Elevate the legs 15 to 20 minutes 4 times a day. Avoid wearing socks that are tight only at the top of the leg.

Following an earthquake, a client who was rescued from a collapsed building is seen in the emergency department. He has blunt trauma to the thorax and abdomen. The nursing observation that most suggests the client is bleeding is:

orthostatic hypotension