Chapter 37. Vascular disorders.
a 46 year old is diagnosed with thromboangiitis obliterans (buergers disease). when the nurse is developing a discharge teaching plan for the pt, which outcome has the highest priority for this pt? a. cessation of all tobacco use b. control of serum lipid levels c. maintenance of appropriate weight d. demonstration of meticulous foot care
a. cessation of all tobacco use
a 67 year old pt is admitted to the hospital with a diagnosis of venous insufficiency. which pt statement is most supportive of the diagnosis? a. i cant get my shoes on at the end of the day b. i cant seem to ever get my feet warm enough c. i have burning leg pains after i walk two blocks d. i wake up during the night because my legs hurt
a. i cant get my shoes on at the end of the day
the nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. on assessment, the pt has absent popliteal, posterior tibial, and dorsalis pedis pulses. the legs are cool and mottled. which action should the nurse take first? a. notify the surgeon and anesthesiologist b. wrap both the legs in a warming blanket c. document the findings and recheck in 15 mins d. compare findings to the preoperative assessment of the pulses.
a. notify the surgeon and anesthesiologist
an 80 year old pt with a history of abdominal aortic aneurysm arrives at the ED with severe back pain and absent pedal pulses. which actions should the nurse take first? a. obtain the BP b. obtain blood for lab testing c. assess for the presence of an abdominal bruit d. determine any family history of kidney disease
a. obtain the BP
a pt 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 pt teaching about PAD management? a. statins b. antibiotics c. thrombolytics d. anticoagulants
a. statins
after teaching a pt with a newly diagnosed raynaud's phenomenon about how to manage the condition, which action by the pt demonstrates that the teaching has been effective? a. the pt exercises indoors during the winter months b. the pt places the hands in hot water when they turn pale c. the pt takes pseudoephedrine for cold symptoms d. the pt avoids taking NSAIDs.
a. the pt exercises indoors during the winter months
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 LPN/LVN caring for the pt requires the RN to intervene? a.. the LPN/LVN has the pt sit in a chair for 90 minutes b. the LPN/LVN assists the pt to walk 40 feet in the hallway c. the LPN/LVN gives the ordered aspirin 160 mg after breakfast d. the LPN/LVN places the pt in a fowlers position for meals.
a.. the LPN/LVN has the pt sit in a chair for 90 minutes
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? a. "I should get a Medic Alert device stating that I take Coumadin." b. "I should reduce the amount of green, leafy vegetables that I eat." c. "I will need routine blood tests to monitor the effects of the Coumadin." d. "I will check with my health care provider before I begin any new medications."
b. "I should reduce the amount of green, leafy vegetables that I eat."
When developing a teaching plan for a 76-year-old patient newly diagnosed with peripheral artery disease (PAD), which instructions should the nurse include? a. "Exercise only if you do not experience any pain." b. "It is very important that you stop smoking cigarettes." c. "Try to keep your legs elevated whenever you are sitting." d. "Put elastic compression stockings on early in the morning."
b. "It is very important that you stop smoking cigarettes."
which actions could the nurse delegate to the UAP who are providing care for a pt who is at risk for VTE? a. monitor for any bleeding after anticoagulation therapy is started b. apply sequential compression device whenever the pt is in bed c. ask the pt about use of herbal medicines or dietary supplements d. instruct the pt to call immediately if any SOB occurs
b. apply sequential compression device whenever the pt is in bed
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)? a. Patient who has been complaining of increased edema and skin changes in the legs b. Patient who needs wound care for a chronic venous stasis ulcer on the right lower leg c. Patient who has a history of venous thromboembolism and is complaining of some dyspnea d. Patient who needs teaching about the use of elastic compression stockings for venous insufficiency
b. Patient who needs wound care for a chronic venous stasis ulcer on the right lower leg
the HCP prescribes an infusion of heparin and daily partial thromboplastin time (PTT) testing for a pt with venous thromboembolism (VTE) the nurse will plan to: a. decrease the infusion when the PTT value is 65 seconds b. avoid giving any IM meds to prevent localized bleeding c. monitor posterior tibial and dorsalis pedis pulses with the doppler d. have vitamin K available in case reversal of the heparin is needed.
b. avoid giving any IM meds to prevent localized bleeding
when caring for a pt on the first postop day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the HCP? a. presence of flatus b. loose, bloody stools c. hypoactive bowel sounds d. abdominal pain with palpation
b. loose, bloody stools
which nursing action should be included in the plan of care after endovascular repair of an abdominal aortic aneurysm? a. record hourly chest tube drainage b. monitor fluid intake and urine output c. check the abdominal incision for any redness d. teach the reason for a prolonged recovery period
b. monitor fluid intake and urine output
the nurse is caring for a pt 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? a. begin oral intake b. obtain VS c. assess pedal pulses d. start discharge teaching
b. obtain VS
a pt has a 6-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. when obtaining an admission history from the pt, it will be most important for the nurse to ask about: a. low back pain b. trouble swallowing c. abdominal tenderness d. changes in bowel habits
b. trouble swallowing
when evaluating the discharge teaching for a pt with chronic peripheral artery disease, the nurse determines a need for further instruction when the pt says, "I will...": a. have to buy some loose clothes that do not bind across my legs or waist b. use a heating pad on my feet at night to increase the circulation and warmth in my feet c. change my position every hour and avoid long periods of sitting with my legs crossed d. walk to the point of pain, rest, and walk again until the pain returns for at least 30 mins 3 times a week.
b. use a heating pad on my feet at night to increase the circulation and warmth in my feet
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 most appropriate? a. "Taking two blood thinners reduces the risk for another clot to form." b. "Lovenox will start to dissolve the clot, and Coumadin will prevent any more clots from forming." c. "Lovenox will work right away, but Coumadin takes several days to have an effect on preventing clots." d. "Because of the risk for a blood clot in the lungs, it is important for you to take more than one blood thinner."
c. "Lovenox will work right away, but Coumadin takes several days to have an effect on preventing clots."
after receiving report, which pt admitted to the ED should the nurse assess first? a. 67 year old who has a gangrenous left foot ulcer with a weak pedal pulse b. 58 year old who is taking anticoagulants for atrial fibrillation and has black stools c. 50 year old who is complaining of sudden sharp and worse ever upper back pain d. 39 year old who has right calf tenderness, redness, and swelling after a long plane ride
c. 50 year old who is complaining of sudden sharp and worse ever upper back pain
the nurse is caring for a pt with a descending aortic dissection. which assessment finding is most important to report to the HCP? a. weak pedal pulses b. absent bowel sounds c. BP 137/88 mm Hg d. 25 mL urine output over the last hour
c. BP 137/88 mm Hg
a 23 year old pt tells the HCP about experiencing cold, numb fingers when running during the winter and raynaud's phenomenon is suspected. the nurse will anticipate teaching the pt about tests for: a. hyperglycemia b. hyperlipidemia c. autoimmune disorders d. coronary artery disease
c. autoimmune disorders
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 pt before discharge? a. sitting at the work counter, rather than standing, is recommended b. exercise, such as walking or jogging, can cause recurrence of varicosities c. elastic compression stockings should be applied before getting out of bed d. taking an aspirin daily will help prevent clots from forming around venous valves
c. elastic compression stockings should be applied before getting out of bed
which assessment finding for a pt who has been admitted with a right calf venous thromboembolism requires immediate action by the nurse? a. erythema of right lower leg b. complaint of right calf pain c. new onset SOB d. temperature 100.4 F
c. new onset SOB
the nurse performing an assessment with a pt who has chronic peripheral artery disease of the legs and an ulcer on the right second toe would expect to find: a. dilated superficial veins b. swollen, dry, scaly ankles c. prolonged capillary refill in all the toes d. a serosanguineous drainage from the ulcer
c. prolonged capillary refill in all the toes
which action by a nurse who is giving fondaparinux to a pt with a lower leg venous thromboembolism indicates that more education about the drug is needed? a. the nurse avoids rubbing the injection site after giving the drug b. the nurse injects the drug into the abdominal subcut tissue c. the nurse ejects the air bubble in the syringe before giving the drug. d. the nurse fails to assess the partial thromboplastin time (PTT) before giving the drug.
c. the nurse ejects the air bubble in the syringe before giving the drug.
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? a. "When I stand too long, my feet start to swell." b. "I get short of breath when I climb a lot of stairs." c. "My fingers hurt when I go outside in cold weather." d. "My legs cramp whenever I walk more than a block."
d. "My legs cramp whenever I walk more than a block."
Which topic should the nurse include in patient teaching for a patient with a venous stasis ulcer on the left lower leg? a. Need to increase carbohydrate intake b. Methods of keeping the wound area dry c. Purpose of prophylactic antibiotic therapy d. Application of elastic compression stockings
d. Application of elastic compression stockings
When discussing risk factor modification for a 63-year-old patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus discharge teaching on which patient risk factor? a. Male gender b. Turner syndrome c. Abdominal trauma history d. Uncontrolled hypertension
d. Uncontrolled hypertension
a pt 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: a. check for the presence of tortuous veins bilaterally on the legs b. ask about any skin color changes that occur in response to cold c. assess for unilateral swelling, redness, and tenderness of either leg d. assess for the presence of the dorsalis pedis and posterior tibial pulses
d. assess for the presence of the dorsalis pedis and posterior tibial pulses
Several hours after an open surgical repair of an abdominal aortic aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has been 40 mL. The nurse notifies the health care provider and anticipates an order for a(n) a. hemoglobin count. b. additional antibiotic. c. decrease in IV infusion rate. d. blood urea nitrogen (BUN) level.
d. blood urea nitrogen (BUN) level.
a pt is being evaluated for post-thrombotic syndrome. which assessment will the nurse perform? a. ask about leg pain with exercise b. determine the ankle-brachial index c. assess capillary refill in the pts toes d. check for presence of lipodermatosclerosis
d. check for presence of lipodermatosclerosis
which nursing intervention for a pt who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to the UAP? a. monitor the quality and presence of the pedal pulses b. teach the pt the signs of possible wound infection c. check the lower extremities for strength and movement d. help the pt to use a pillow to splint while coughing
d. help the pt to use a pillow to splint while coughing
a 73 year old pt with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. the nurse should notify the HCP and immediately: a. apply a compression stocking to the leg b. elevate the leg above the level of the heart c. assist the pt in gently exercising the leg d. keep the pt in bed in the supine position
d. keep the pt in bed in the supine position
the HCP has prescribed bed rest with the feet elevated for a pt admitted to the hospital with venous thromboembolism. which action by the nurse to elevate the pts feet is best? a. the pt is placed in the trendelenburg position. b. two pillows are positioned under the affected leg c. the bed is elevated at the knee and pillows are placed under the feet d. one pillow is placed under the thighs and two pillows are placed under the lower legs
d. one pillow is placed under the thighs and two pillows are placed under the lower legs
