Ch. 30 Cardiac M/S 2

A community health nurse teaches a group of older adults about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which statement?

"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."

The nurse is monitoring a patient who is on heparin anticoagulant therapy. What should the nurse determine the therapeutic range of the international normalized ratio (INR) should be?

2.0-3.0

Heparin therapy is usually considered therapeutic when the activated partial thromboplastin time (aPTT) is how many times higher than a normal value?

2 to 2.5

When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows that therapeutic benefits will not occur for:

3 to 5 days.

A nursing instructor is discussing the diagnosis of intermittent claudication with students. To determine whether the students understand the pathophysiology of the disease, the instructor asks, "What percentage of the arterial lumen must be obstructed before intermittent claudication is experienced?" What answer should the students give?

50

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection?

Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute

The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack?

Avoid situations that contribute to ischemic episodes.

When teaching a client with peripheral vascular disease about foot care, a nurse should include which instruction?

Avoid wearing canvas shoes.

Health teaching includes advising patients on ways to reduce PAD. The nurse should always emphasize that the strongest risk factor for the development of atherosclerotic lesions is:

Cigarette smoking.

A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following?

Constant, intense back pain and falling blood pressure

A patient who had a colon resection 3 days ago is complaining of discomfort in the left calf. How should the nurse assess Homan's sign to determine if the patient may have a thrombus formation in the leg?

Dorsiflex the foot while the leg is elevated to check for calf pain.

As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client?

Demonstrate how to apply and remove elastic support stockings.

The nurse assessing a client who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which characteristic?

Diminished or absent pulses

Which is a characteristic of arterial insufficiency?

Diminished or absent pulses

Which aneurysm results in bleeding into the layers of the arterial wall?

Dissecting

A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency?

Elevate the legs periodically for at least 15 to 20 minutes.

A patient is having an angiography to detect the presence of an aneurysm. After the contrast is administered by the interventionist, the patient begins to complain of nausea and difficulty breathing. What medication is a priority to administer at this time?

Epinephrine

Which statement is accurate regarding Reynaud disease?

Episodes may be triggered by unusual sensitivity to cold.

Which class of medication lyses and dissolves thrombi?

Fibrinolytic

Which of the following are complications of percutaneous transluminal balloon angioplasty (PTA)? Select all that apply.

Hematoma Embolization Dissection of the vessel Bleeding Stent migration

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time?

Ineffective peripheral tissue perfusion related to venous congestion

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

A client is diagnosed with peripheral arterial disease. Review of the client's chart shows an ankle-brachial index (ABI) on the right of 0.45. This indicates that the right foot has which of the following?

Moderate to severe arterial insufficiency

A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment?

Numbness, cool skin temperature, and pallor

Which risk factor is related to venous stasis for deep vein thrombosis (DVT) and pulmonary embolism (PE)?

Obesity

A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities?

Participate in a regular walking program.

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?

Protamine sulfate

A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions?

Stabilizing heart rate and blood pressure and easing anxiety

A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client?

Stop smoking.

What should the nurse do to manage the persistent swelling in a client with severe lymphangitis and lymphadenitis?

Teach the client how to apply an elastic sleeve

A client with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which is the most likely cause?

The aneurysm may be preparing to rupture.

A nurse and physician are preparing to visit a hospitalized client with peripheral arterial disease. As you approach the client's room, the physician asks if the client has reported any intermittent claudication. The client has reported this symptom. The nurse explains to the physician which of the following details?

The client can walk about 50 feet before getting pain in the right lower leg.

Which of the following is the most common site for a dissecting aneurysm?

Thoracic area

The nurse is caring for a patient with venous insufficiency. For what should the nurse assess the patient's lower extremities?

Ulceration

What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue?

Ulcers and infection in the edematous area

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gaiter area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect?

Venous insufficiency

The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is

contrast phlebography.

To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a 45-degree angle and then have the client sit up. The nurse suspects arterial insufficiency if the assessment reveals:

elevational pallor.

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by:

forcing blood into the deep venous system.