CH 30 PrepU

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 nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures?

"I have my wife look at the soles of my feet each day."

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."

A client admitted to the medical-surgical unit with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are needed. Which response by the nurse is accurate?

"The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect."

The nurse is assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse include in the education of the patient during ambulation?

"Walk to the point of pain, rest until the pain subsides, then resume ambulation."

When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of:

1.5 to 2.5 times the baseline control.

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

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

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

Which of the following medications is considered a thrombolytic?

Alteplase

A patient is admitted to a special critical care unit for the treatment of an arterial thrombus. The nurse is aware that the preferred drug of choice for clot removal, unless contraindicated, would be:

Alteplase.

The nurse is assessing a patient two days postoperatively who is suspected of having deep vein obstruction. The patient is complaining of pain in the left lower extremity and there is a 2-cm difference in the right and left leg circumference. What intervention can the nurse provide to promote arterial flow to the lower extremities?

Apply a heating pad to the patient's abdomen.

A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following?

Arterial insufficiency

You are presenting a workshop at the senior citizens center about how the changes of aging predisposes clients to vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in the older adult?

Atherosclerosis

A client in the emergency department states, "I have always taken a morning walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." Based on this statement, which priority assessment should the nurse complete?

Attempt to palpate the dorsalis pedis and posterior tibial pulses.

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

A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless temporary change?

Bluish urine

Which of the following is a characteristic of an arterial ulcer?

Border regular and well demarcated

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.

Pentoxifylline (Trental) is a medication used for which of the following conditions?

Claudication

Health teaching for a patient diagnosed with Raynaud's phenomenon would include advising the patient to avoid the most common factor known to trigger episodes. Which of the following is the most common factor?

Cold and stress

Which of the following is a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot?

Contrast phlebography

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.

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 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

Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of:

Hemorrhage.

A client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of thromboembolism?

Homans'

A patient with diabetes is being treated for a wound on the lower extremity that has been present for 30 days. What option for treatment is available to increase diffusion of oxygen to the hypoxic wound?

Hyperbaric oxygen

The nurse is caring for a patient who has started anticoagulant therapy with warfarin (Coumadin). When does the nurse understand that therapeutic benefits will begin?

In 3 to 5 days

Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending?

Increased abdominal and back pain

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 of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity?

Intermittent claudication

A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued?

International normalized ratio (INR) is 2.5.

The nurse is caring for a patient with peripheral arterial insufficiency. What can the nurse suggest to help relieve leg pain during rest?

Lowering the limb so that it is dependent

With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by:

Lowering the limb so that it is dependent.

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

Aortic dissection may be mistaken for which of the following disease processes?

Myocardial infarction (MI)

Which is a risk factor for venous disorders of the lower extremities?

Obesity

A client with Raynaud's disease complains of cold and numbness in the fingers. Which of the following would the nurse identify as an early sign of vasoconstriction?

Pallor

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 nurse is caring for a client following an arterial vascular bypass graft in the leg. What should the nurse plan to assess over the next 24 hours?

Peripheral pulses every 15 minutes after surgery

A patient complains of a "stabbing pain and a burning sensation" in his left foot. The nurse notices that the foot is a lighter color than the rest of the skin. The artery that the nurse suspects is occluded would be the:

Posterior tibial.

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 orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs?

Prothrombin time (PT)

A client with systemic lupus erythematosus (SLE) complains that his hands become pale, blue, and painful when exposed to the cold. What disease should the nurse cite as an explanation for these signs and symptoms?

Raynaud's disease

Which of the following is the most effective intervention for preventing progression of vascular disease?

Risk factor modification

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

Which of the following are alterations noted in Virchow's triad? Select all that apply.

Stasis of blood Vessel wall injury Altered coagulation

On a routine visit to the physician, a client with chronic arterial occlusive disease reports that he's stopped smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, which additional measure should the nurse recommend?

Taking daily walks

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

Teach the client how to apply a graduated compression stocking.

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.

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. What should the nurse assess the patient's lower extremities for?

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 gater 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

A client has been diagnosed with Raynaud's disease. Which self-care strategies minimize risks associated with this disease? Select all that apply.

Wear gloves to protect hands from injury when performing tasks. Do not smoke, or stop smoking. Avoid over-the-counter decongestants and cold remedies.

Which of the following assessment results is considered a major risk factor for PAD?

Which of the following assessment results is considered a major risk factor for PAD?

The most common site of aneurysm formation is in the:

abdominal aorta, just below the renal arteries.

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:

dependent 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.

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should:

keep the affected leg level or slightly dependent.

The nurse teaches the client with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes

vasospasm.