chapter 37 vascular disorders

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 patients ankle-brachial index (ABI) as ________ (round up to the nearest hundredth).

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

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

keep the patient in bed in the supine position.

23. After receiving report, which patient admitted to the emergency department should the nurse assess first?

50-year-old who is complaining of sudden sharp and worst ever upper back pain

15. Which topic should the nurse include in patient teaching for a patient with a venous stasis ulcer on the left lower leg?

Application of elastic compression stockings

33. 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?

Apply sequential compression device whenever the patient is in bed.

28. A 46-year-old is diagnosed with thromboangiitis obliterans (Buergers disease). When the nurse is developing a discharge teaching plan for the patient, which outcome has the highest priority for this patient?

Cessation of all tobacco use

32. A patient is being evaluated for post-thrombotic syndrome. Which assessment will the nurse perform?

Check for presence of lipodermatosclerosis.

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?

Combined clopidogrel and omeprazole therapy

14. A 46-year-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Which instructions should the nurse provide to the patient before discharge?

Elastic compression stockings should be applied before getting out of bed.

30. Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

Help the patient to use a pillow to splint while coughing.

16. 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?

I cant get my shoes on at the end of the day.

13. The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) following hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says which of the following?

I should reduce the amount of green, leafy vegetables that I eat.

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?

It is very important that you stop smoking cigarettes.

12. A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is mostappropriate?

Lovenox will work right away, but Coumadin takes several days to have an effect on preventing clots.

20. 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?

My legs cramp whenever I walk more than a block.

29. Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse?

New onset shortness of breath

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?

Obtain vital signs.

10. 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 patients feet is best?

One pillow is placed under the thighs and two pillows are placed under the lower legs.

34. 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)?

Patient who needs wound care for a chronic venous stasis ulcer on the right lower leg

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?

Statins

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?

The LPN/LVN has the patient sit in a chair for 90 minutes.

18. Which action by a nurse who is giving fondaparinux (Arixtra) to a patient with a lower leg venous thromboembolism (VTE) indicates that more education about the drug is needed?

The nurse ejects the air bubble in the syringe before giving the drug.

9. After teaching a patient with newly diagnosed Raynauds phenomenon about how to manage the condition, which action by the patient demonstrates that the teaching has been effective?

The patient exercises indoors during the winter months.

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

assess for the presence of the dorsalis pedis and posterior tibial pulses.

19. A 23-year-old patient tells the health care provider about experiencing cold, numb fingers when running during the winter and Raynauds phenomenon is suspected. The nurse will anticipate teaching the patient about tests for

autoimmune disorders.

11. 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

avoid giving any IM medications to prevent localized bleeding.

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

prolonged capillary refill in all the toes.

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

use a heating pad on my feet at night to increase the circulation and warmth in my feet.