Cardio - NCLEX Saunders (Cardio/Peripheral Vascular Disorders)

The nurse is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client? Select all that apply. 1. Wear elastic stockings. 2. Be careful not to injure the legs or feet. 3. Use a heating pad on the legs to aid vasodilation. 4. Walk each day to increase circulation to the legs. 5. Cut down on the amount of fats consumed in the diet.

2. Be careful not to injure the legs or feet. 4. Walk each day to increase circulation to the legs. 5. Cut down on the amount of fats consumed in the diet. Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), relieve pain, and maintain tissue integrity (foot care and nutrition). Elastic stockings will not increase circulation. They are worn with peripheral vascular disease, but not peripheral arterial disease. Application of heat directly to the extremity is contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Direct application of heat raises oxygen and nutritional requirements of the tissue even further.

The nurse is collecting data from a client about medications being taken, and the client tells the nurse that he is taking herbal supplements for the treatment of varicose veins. The nurse understands that the client is most likely taking which? A. Bilberry B. Ginseng C. Feverfew D. Evening primrose

A. Bilberry Bilberry is an herbal supplement that has been used to treat varicose veins. This supplement has also been used to treat cataracts, retinopathy, diabetes mellitus, and peripheral vascular disease. Ginseng has been used to improve memory performance and decrease blood glucose levels in type 2 diabetes mellitus. Feverfew is used to prevent migraine headaches and to treat rheumatoid arthritis. Evening primrose is used to treat eczema and skin irritation.

The nurse is evaluating the effects of care for the client with deep vein thrombosis. Which limb observations should the nurse note as indicating the least success in meeting the outcome criteria for this problem? A. Pedal edema that is 3+ B. Slight residual calf tenderness C. Skin warm, equal temperature both legs D. Calf girth ⅛ inch larger than unaffected limb

A. Pedal edema that is 3+ Symptoms of deep vein thrombosis include leg warmth, redness, edema, tenderness, and enlarged calf. If the problem is not resolved, or is minimally resolved, these symptoms will remain. Option 3 indicates full resolution of the problem, whereas options 2 and 4 indicate partial resolution. Option 1 is the correct option because it indicates the least degree of symptom reversal.

The nurse notes bilateral 2+ edema in the lower extremities of a client with known coronary artery disease who was admitted to the hospital 2 days ago. Based on this finding, the nurse should implement which action? A. Reviews the intake and output records for the last 2 days B. Prescribes daily weights starting on the following morning C. Changes the time of diuretic administration from morning to evening D. Requests a sodium restriction of 1 g/day from the health care provider

A. Reviews the intake and output records for the last 2 days Edema is the accumulation of excess fluid in the interstitial spaces, which can be determined by intake greater than output and by a sudden increase in weight (2.2 lb = 1 kg). To determine the extent of fluid accumulation, the nurse first reviews the intake and output records for the past 2 days. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms.

A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. The nurse should check the client for which next? A. Smoking history B. Recent exposure to allergens C. History of recent insect bites D. Familial tendency toward peripheral vascular disease

A. Smoking history The mixture of arterial and venous manifestations (claudication and phlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger's disease). This is a relatively uncommon disorder, characterized by inflammation and thrombosis of smaller arteries and veins. This disorder is typically found in young men who smoke. The cause is unknown but is suspected to have an autoimmune component.

The nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is available for emergency use? A. Surgical tourniquet B. Dry sterile dressings C. Incentive spirometer D. Over-the-bed trapeze

A. Surgical tourniquet Monitoring for complications is an important aspect of initial postoperative care. Vital signs and pulse oximetry values are monitored closely until the client's condition stabilizes. The wound and any drains are monitored closely for excessive bleeding because hemorrhage is the primary immediate complication of amputation. Therefore, a surgical tourniquet needs to be readily available in case of acute bleeding. An over-the-bed trapeze increases the client's independence in self-care activities but is not a priority in the immediate postoperative period. An incentive spirometer and dry sterile dressings also should be available, but these are not priority items.

The nurse reinforces instructions to a client at risk for thrombophlebitis regarding measures to minimize its occurrence. Which statement by the client indicates an understanding of this information? A. "I need to avoid pregnancy by taking oral contraceptives." B. "I should avoid sitting in one position for long periods of time." C. "I can finally stop wearing these support stockings that you gave me." D. "I will be sure to maintain my fluid intake to at least four glasses daily."

B. "I should avoid sitting in one position for long periods of time." Avoidance of sitting or standing for a prolonged period of time is one of the measures for the prevention of venous stasis and thrombophlebitis. Taking oral contraceptives causes hypercoagulability that could result in thrombophlebitis. Support stockings are used to promote venous return, to maintain normal coagulability, and to prevent injury to the endothelial wall. Adequate hydration is maintained to prevent hypercoagulability, and four glasses daily are an inadequate amount of fluid.

The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client states which? A. "Smoking cessation is very important." B. "Moving to a warmer climate should help." C. "Sources of caffeine should be eliminated from the diet." D. "Taking nifedipine (Procardia) as prescribed will decrease vessel spasm."

B. "Moving to a warmer climate should help." Raynaud's disease responds favorably to the elimination of nicotine and caffeine. Medications such as calcium channel blockers may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is very important. However, moving to a warmer climate may not necessarily be beneficial because the symptoms could still occur with the use of air conditioning and during periods of cooler weather.

A client who has undergone femoropopliteal bypass grafting says to the nurse, "I hope I don't have any more problems that could make me lose my leg. I'm so afraid that I'll have gone through this for nothing." Which is an appropriate nursing response? A. "There is nothing to worry about." B. "You are concerned about losing your leg?" C. "There are many people with the same problem, and they are doing just fine." D. "You have the best health care provider in the city, and your health care provider will not let anything happen to you."

B. "You are concerned about losing your leg?" The appropriate response is the one that uses the therapeutic technique of restatement. Option 2 restates the client's concern and provides an opportunity for the client to further discuss the concern. Options 1, 3, and 4 are inappropriate because they provide false reassurance and do not address the client's concern.

The nurse is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA? A. Pulsatile abdominal mass B. Hyperactive bowel sounds in the area C. Systolic bruit over the area of the mass D. Subjective sensation of "heart beating" in the abdomen

B. Hyperactive bowel sounds in the area Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the "heart beating" in the abdomen when supine, or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not specifically related to an abdominal aortic aneurysm.

The nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is which? A. Moderately impaired, and the surgeon should be called B. Normal, caused by increased blood flow through the leg C. Slightly deteriorating, and should be monitored for another hour D. Adequate from an arterial approach, but venous complications are arising

B. Normal, caused by increased blood flow through the leg An expected outcome of surgery is warmth, redness, and edema in the surgical extremity caused by increased blood flow. Options 1, 3, and 4 are incorrect.

A client returns to the nursing unit after an above knee amputation of the right leg. In which position should the nurse place the client? A. Prone with the head on a pillow B. With the foot of the bed elevated C. Reverse Trendelenburg's position D. With the residual limb flat on the bed

B. With the foot of the bed elevated During the first 24 hours after amputation, the nurse elevates the foot of the bed (but not the residual limb itself) to reduce edema. After the first 24 hours, the bed is kept flat to prevent hip flexion contractures. The health care provider's postoperative prescriptions regarding positioning are always followed.

A client has an inoperable abdominal aortic aneurysm (AAA). Which measure should the nurse anticipate reinforcing when teaching the client? A. Bed rest B. Restricting fluids C. Antihypertensives D. Maintaining a low-fiber diet

C. Antihypertensives The medical treatment for abdominal aortic aneurysm is controlling blood pressure. Hypertension creates added stress on the blood vessel wall, increasing the likelihood of rupture. There is no need for the client to restrict fluids or to be on bed rest. A low-fiber diet is not helpful and will cause constipation.

A client is diagnosed with thrombophlebitis. The nurse should tell the client that which prescription is indicated? A. Bed rest, with bathroom privileges only B. Bed rest, keeping the affected extremity flat C. Bed rest, with elevation of the affected extremity D. Bed rest, with the affected extremity in a dependent position

C. Bed rest, with elevation of the affected extremity Elevation of the affected leg facilitates blood flow by the force of gravity and decreases venous pressure, which in turn relieves edema and pain. The foot of the bed is elevated and bed rest is indicated to prevent emboli and pressure fluctuations in the venous system that occur with walking. The positions in the remaining options are incorrect.

The client scheduled for a right femoropopliteal bypass graft is at risk for compromised tissue perfusion to the extremity. The nurse takes which action before surgery to address this risk? A. Having the client void before surgery B. Completing a preoperative checklist C. Marking the location of the pedal pulses on the right leg D. Checking the results of any baseline coagulation studies

C. Marking the location of the pedal pulses on the right leg A problem with compromised tissue perfusion in the client scheduled for a femoropopliteal bypass grafting is likely to indicate the presence of diminished peripheral pulses. It is important to mark the location of any pulses that are palpated or auscultated. This provides a baseline for comparison in the postoperative period. The other options are part of routine preoperative care.

The nurse is caring for a client diagnosed with Buerger's disease. Which finding should the nurse determine is a potential complication associated with this disease? A. Pain with diaphoresis B. Discomfort in one digit C. Numbness and tingling in the legs D. Cramping in the foot while resting

C. Numbness and tingling in the legs Buerger's disease (thromboangiitis obliterans), which affects men between 20 and 40 years of age, has an unknown etiology. It is a recurring inflammation of the small and medium-sized arteries and veins of the upper and lower extremities that results in thrombus formation and occlusion of blood vessels. Options 1, 2, and 4 are not complications of this disorder. The finding that can be interpreted as a complication of the disorder is numbness and tingling in the legs.

A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The nurse understands that a life-threatening complication of this condition is which? A. Pneumonia B. Pulmonary edema C. Pulmonary embolism D. Myocardial infarction

C. Pulmonary embolism Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension.

A client has an Unna boot applied for treatment of a venous stasis leg ulcer. The nurse notes that the client's toes are mottled, and cool and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings? A. The boot has not yet dried. B. The boot is controlling leg edema. C. The boot is impairing venous return. D. The boot has been applied too tightly.

D. The boot has been applied too tightly. An Unna boot that is applied too tightly can cause signs of arterial occlusion. The nurse assesses the circulation in the foot and teaches the client to do the same. The other options are incorrect interpretations.

The nurse is collecting data from a client with varicose veins. Which finding would the nurse identify as an indication of a potential complication associated with this disorder? A. Legs are unsightly in appearance and distress the client. B. The client complains of aching and feelings of heaviness in the legs. C. The client complains of leg edema, and skin breakdown has started. D. The health care provider finds that the legs become distended when the tourniquet is released during the Trendelenburg's test.

C. The client complains of leg edema, and skin breakdown has started. Complications of varicose veins include leg edema, skin breakdown, ulceration of the legs, trauma leading to rupture of a varicosity, deep vein thrombosis, or chronic insufficiency. The client with varicose veins may be distressed about the unsightly appearance of the varicosities. Complaints of heaviness and aching in the legs are common. Option 4 describes the Trendelenburg's test findings, which are indicative of varicose veins. In the test, the health care provider has the client lie down and elevate the legs to empty the veins. A tourniquet is then applied to occlude the superficial veins, after which the client stands and the tourniquet is released. If the veins are incompetent, they will quickly become distended due to backflow.

A client is seen in the health care provider's office for a physical examination after experiencing unusual fatigue over the last several weeks. Height is 5 feet, 8 inches, with a weight of 220 pounds. Vital signs are temperature 98.6° F oral, pulse 86 beats per minute, respirations 18 breaths per minute, and blood pressure 184/96 mm Hg. Random blood glucose is 110 mg/dL. In order to best collect relevant data, which question should the nurse ask the client first? A. "Do you exercise regularly?" B. "Would you consider losing weight?" C. "Is there a history of diabetes mellitus in your family?" D. "When was the last time you had your blood pressure checked?"

D. "When was the last time you had your blood pressure checked?" The client is hypertensive, which is a known major modifiable risk factor for coronary artery disease (CAD). The other major modifiable risk factors for CAD not exhibited by this client include smoking and hyperlipidemia. The client is overweight, which is also a contributing risk factor. The client's nonmodifiable risk factors are age and gender. Because the client presents with several risk factors, the nurse places priority on the client's major modifiable risk factors.

A client seeks medical attention for intermittent episodes in which the fingers of both hands become cold, pale, and numb. The client states that they then become reddened and swollen with a throbbing, achy pain and Raynaud's disease is diagnosed. Which factor would precipitate these episodes? A. Exposure to heat B. Being in a relaxed environment C. Prolonged episodes of inactivity D. Ingestion of coffee or chocolate

D. Ingestion of coffee or chocolate Raynaud's disease is a bilateral form of intermittent arteriolar spasm, which can be classified as obstructive or vasospastic. Episodes are characterized by pallor, cold, numbness, and possible cyanosis, followed by erythema, tingling, and aching pain in the fingers. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress.

A client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer expecting to note which observation? A. The ulcer has a pale-colored base. B. The ulcer is deep, with even edges. C. The ulcer has little granulation tissue. D. The ulcer has a brownish or "brawny" appearance.

D. The ulcer has a brownish or "brawny" appearance. Venous leg ulcers, also called stasis ulcers, are typically partial-thick wounds that extend through the epidermis and portions of the dermis. The skin of the lower leg is leathery, with a characteristic brownish or "brawny" appearance from the hemosiderin deposition. The edges of the ulcer are irregular and the tissue is a ruddy color. The client also may exhibit peripheral edema. Therefore, options 1, 2, and 3 are incorrect descriptions.