Chpt 30 PrepU
Which of the following is the most common site for a dissecting aneurysm? a) Cervical area b) Sacral area c) Lumbar area d) Thoracic area
D. Thoracic area Explanation: The thoracic area is the most common site for a dissecting aneurysm. About one-third of patients with thoracic aneurysms die of rupture of the aneurysm.
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? a) 2.0-3.0 b) 7.0-8.0 c) 5.0-6.0 d) 4.0-5.0
a. 2.0-3.0 Explanation: Oral anticoagulants, such as warfarin, are monitored by the PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved
The nurse performing an assessment on a patient who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which of the following characteristics? a) Diminished or absent pulses b) Aching, cramping pain c) Pulses are present, may be difficult to palpate d) Superficial ulcer
a. Diminished or absent pulses Explanation: Occlusive arterial disease impairs blood flow and can reduce or obliterate palpable pulsations in the extremities. A diminished or absent pulse is a characteristic of arterial insufficiency.
Which of the following aneurysms results in bleeding into the layers of the arterial wall? a) Dissecting b) False c) Anastomotic d) Saccular
a. Dissecting Explanation: Dissection results from a rupture in the intimal layer, resulting in bleeding between the intimal and medial layers of the arterial wall. Saccular aneurysms collect blood in the weakened outpouching. In a false aneurysm, the mass is actually a pulsating hematoma. An anastomotic aneurysm occurs as a result of infection at arterial suture or graft sites.
With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by: a) Lowering the limb so that it is dependent. b) Placing the limb in a plane horizontal to the body. c) Massaging the limb after application of cold compresses. d) Elevating the limb over the heart level.
a. Lowering the limb so that it is dependent. Explanation: Lowering the extremity to a dependent position improves perfusion to the distal tissues.
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? a) Venous insufficiency b) Arterial insufficiency c) Trauma d) Neither venous nor arterial insufficiency
a. Venous insufficiency Explanation: Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gater area, and a reddish blue color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the anterior tibial area. Characteristics of arterial insufficiency ulcers include location at the tips of the toes, great pain, and circular shape with a pale to black ulcer base.
Which of the following are indications of a rupturing aortic aneurysm? Select all that apply. a) Increasing hematocrit b) Decreasing blood pressure c) Constant, intense back pain d) Decreasing hematocrit e) Increasing blood pressure
b, c, d • Constant, intense back pain • Decreasing blood pressure • Decreasing hematocrit Explanation: Indications of a rupturing abdominal aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit.
A nurse is caring for a client following an arterial vascular bypass graft in the leg. Over the next 24 hours, what should the nurse plan to assess? a) Blood pressure every 2 hours b) Peripheral pulses every 15 minutes following surgery c) Color of the leg every 4 hours d) Ankle-arm indices every 12 hours
b. Peripheral pulses every 15 minutes following surgery Explanation: The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the patient's status remains stable.
A patient admitted to the medical surgical unit with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are needed. Which response by the nurse is accurate? a) "Lovenox will dissolve the clot, and Coumadin will prevent any more clots from occurring." b) "The Lovenox will work immediately, but the Coumadin takes several days to reach its full effect." c) "Administration of two anticoagulants decreases the risk of recurrent venous thrombosis." d) "Because of the potential for a pulmonary embolism, it is important for you to have at least two anticoagulants."
b. "The Lovenox will work immediately, but the Coumadin takes several days to reach its full effect." Explanation: Oral anticoagulants, such as warfarin, are monitored by the prothrombin time (PT) or the international normalized ratio (INR). Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (ie, when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0)
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? a) "If you feel any discomfort, stop and we will use a wheelchair to take you back to your room." b) "Walk to the point of pain, rest until the pain subsides, then resume ambulation." c) "As soon as you feel pain, we will go back and elevate your legs." d) "If you feel pain during the walk, keep walking until the end of the hallway is reached."
b. "Walk to the point of pain, rest until the pain subsides, then resume ambulation." Explanation: The nurse instructs the patient to walk to the point of pain, rest until the pain subsides, and then resume walking so that endurance can be increased as collateral circulation develops. Pain can serve as a guide in determining the appropriate amount of exercise.
Which of the following medication classifications is more likely to be expected when the nurse is caring for a client with atrial fibrillation? a) Diuretic b) Anticoagulant c) Potassium supplement d) Antihypertensive
b. Anticoagulant Explanation: Clients with persistent atrial fibrillation are prescribed anticoagulation therapy to reduce the risk of emboli formation associated with ineffective circulation. The other options may be prescribed but not expected in most situations.
The nurse in the intensive care unit (ICU) hears an alarm sound in the patient's room. Arriving in the room, the patient is unresponsive, without a pulse, and a flat line on the monitor. What is the first action by the nurse? a) Administer epinephrine b) Begin cardiopulmonary resuscitation (CPR) c) Defibrillate with 360 joules (monophasic defibrillator) d) Administer atropine 0.5 mg
b. Begin cardiopulmonary resuscitation (CPR) Explanation: Commonly called flatline, ventricular asystole (Fig. 26-19) is characterized by absent QRS complexes confirmed in two different leads, although P waves may be apparent for a short duration. There is no heartbeat, no palpable pulse, and no respiration. Without immediate treatment, ventricular asystole is fatal. Ventricular asystole is treated the same as PEA, focusing on high-quality CPR with minimal interruptions and identifying underlying and contributing factors.
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? a) Higher than normal blood pressure and falling hematocrit b) Constant, intense back pain and falling blood pressure c) Constant, intense headache and falling blood pressure d) Slow heart rate and high blood pressure
b. Constant, intense back pain and falling blood pressure Explanation: Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit.
Which medication is indicated for the patient with atrial fibrillation who is at high risk for stroke? a) Plavix b) Coumadin c) Lovenox d) Aspirin
b. Coumadin Explanation: Warfarin (Coumadin) is indicated if the patient with atrial fibrillation is at high risk for stroke. Aspirin, Lovenox, and Plavix are not indicated. If immediate anticoagulation is necessary, the patient may be placed on heparin until the warfarin level is therapeutic.
Which of the following is a potential cause of premature ventricular complexes (PVCs)? a) Alkalosis b) Hypokalemia c) Bradycardia d) Hypovolemia
b. Hypokalemia Explanation: PVCs can be caused by cardiac ischemia or infarction, increased workload on the heart (eg, exercise, fever, hypervolemia, heart failure, tachycardia), digitalis toxicity, acidosis, or electrolyte imbalances, especially hypokalemia
A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? a) Risk for injury related to edema b) Ineffective peripheral tissue perfusion related to venous congestion c) Impaired gas exchange related to increased blood flow d) Excess fluid volume related to peripheral vascular disease
b. Ineffective peripheral tissue perfusion related to venous congestion Explanation: Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with DVT. Impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Excess fluid volume related to peripheral vascular disease is inappropriate because there's no evidence that this client has an excess fluid volume. Risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion.
Which of the following are risk factors for venous disorders of the lower extremities? a) Trauma b) Obesity c) Pacing wires d) Surgery
b. Obesity Explanation: Careful assessment is invaluable in detecting early signs of venous disorders of the lower extremities. Patients with a history of varicose veins, hypercoagulation, neoplastic disease, cardiovascular disease, or recent major surgery or injury are at high risk. Other patients at high risk include those who are obese or older adults and women taking oral contraceptives.
The most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program is that this form of exercise: a) aids in weight reduction. b) increases high-density lipoprotein (HDL) level. c) reduces stress. d) decreases venous congestion.
d. decreases venous congestion. Explanation: Regular walking is the best way to decrease venous congestion because using the leg muscles as a pump helps return blood to the heart. Regular exercise also aids in stress reduction and weight reduction and increases the formation of HDLs — which are all beneficial to a client with peripheral vascular disease. However, these changes don't have as significant an effect on the client's condition as decreasing venous congestion.
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? a) Decreasing blood pressure and increasing mobility b) Stabilizing heart rate and blood pressure and easing anxiety c) Increasing blood pressure and reducing mobility d) Increasing blood pressure and monitoring fluid intake and output
b. Stabilizing heart rate and blood pressure and easing anxiety Explanation: For a client with an aneurysm, nursing interventions focus on preventing aneurysm rupture by stabilizing heart rate and blood pressure. Easing anxiety also is important because anxiety and increased stimulation may raise the heart rate and boost blood pressure, precipitating aneurysm rupture. The client with an abdominal aortic aneurysm is typically hypertensive, so the nurse should take measures to lower blood pressure, such as administering antihypertensive agents, as ordered, to prevent aneurysm rupture. To sustain major organ perfusion, the client should maintain a mean arterial pressure of at least 60 mm Hg. Although the nurse must assess each client's mobility individually, most clients need bed rest when initially attempting to gain stability.
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: a) shave the affected leg in anticipation of surgery. b) keep the affected leg level or slightly dependent. c) elevate the affected leg as high as possible. d) place a heating pad around the affected calf.
b. keep the affected leg level or slightly dependent. Explanation: While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg could cause accidental trauma from cuts or nicks.
A client presents to the emergency department via ambulance with a heart rate of 210 beats/minute and a sawtooth waveform pattern per cardiac monitor. The nurse is most correct to alert the medical team of the presence of a client with which disorder? a) Asystole b) Ventricular fibrillation c) Atrial flutter d) Premature ventricular contraction
c. Atrial flutter Explanation: Atrial flutter is a disorder in which a single atrial impulse outside the SA node causes the atria to contract at an exceedingly rapid rate. The atrioventricular (AV) node conducts only some impulses to the ventricle, resulting in a ventricular rate slower than the atrial rate, thus forming a sawtooth pattern on the heart monitor. Asystole is the absence of cardiac function and can indicate death. Premature ventricular contraction indicates an early electric impulse and does not necessarily produce an exceedingly rapid heart rate. Ventricular fibrillation is the inefficient quivering of the ventricles and indicative of a dying heart.
The nurse is observing the monitor of a patient with a first-degree atrioventricular (AV) block. What is the nurse aware characterizes this block? a) An irregular rhythm b) P waves hidden with the QRS complex c) Delayed conduction, producing a prolonged PR interval d) A variable heart rate, usually fewer than 60 bpm
c. Delayed conduction, producing a prolonged PR interval Explanation: First-degree AV block occurs when all the atrial impulses are conducted through the AV node into the ventricles at a rate slower than normal. Thus the PR interval is prolonged (>0.20 seconds).
Which of the following medication classifications lyses and dissolves thrombi? a) Factor XA inhibitors b) Platelet inhibitors c) Fibrinolytic d) Anticoagulant
c. Fibrinolytic Explanation: Thrombolytic (fibrinolytic) therapy lyses and dissolves thrombi in 50% of patients. Anticoagulants, platelet inhibitors, and factor XA inhibitors do no lyse or dissolve thrombi.
Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending? a) Decreased pulse rate and blood pressure b) Retrosternal back pain radiating to the left arm c) Increased abdominal and back pain d) Elevated blood pressure and rapid respirations
c. Increased abdominal and back pain Explanation: Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be affected.
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? a) Massage the calf muscles if pain occurs. b) Keep the extremities elevated slightly. c) Participate in a regular walking program. d) Use a heating pad to promote warmth.
c. Participate in a regular walking program. Explanation: Clients diagnosed with peripheral arterial occlusive disease should be encouraged to participate in a regular walking program to help develop collateral circulation. They should be advised to rest if pain develops and to resume activity when pain subsides. Extremities should be kept in a dependent position to promote circulation; elevation of the extremities will decrease circulation. Heating pads should not be used by anyone with impaired circulation to avoid burns. Massaging the calf muscles will not decrease pain. Intermittent claudication subsides with rest.
A healthy 46-year-old woman is seeing her health care provider for her annual physical examination. While the nurse is taking the patient's vital signs, the patient states, "Occasionally, my heart skips a beat. Is this normal?" The nurse explains that this feeling is caused by which of the following? a) Sinus tachycardia b) Ventricular fibrillation c) Premature atrial complex d) Atrial flutter
c. Premature atrial complex Explanation: A premature atrial complex (PAC) is a single ECG complex that occurs when an electrical impulse starts in the atrium before the next normal impulse of the sinus node.
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? a) Engaging in anaerobic exercise b) Reducing daily fat intake to less than 45% of total calories c) Taking daily walks d) Abstaining from foods that increase levels of high-density lipoproteins (HDLs)
c. Taking daily walks Explanation: Taking daily walks relieves symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may make these symptoms worse. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat, not abstain from, foods that raise HDL levels.
The nurse is caring for a patient with venous insufficiency. What should the nurse assess the patient's lower extremities for? a) Cellulitis b) Dermatitis c) Ulceration d) Rudor
c. Ulceration Explanation: Venous ulceration is the most serious complication of chronic venous insufficiency and can be associated with other conditions affecting the circulation of the lower extremities. Cellulitis or dermatitis may complicate the care of chronic venous insufficiency and venous ulcerations.
For a client with thrombosis, what does the nurse do if pulses cannot be palpated? a) Use magnetic resonance imaging b) Use radiography c) Use Doppler ultrasound device d) Use computed tomography scan
c. Use Doppler ultrasound device Explanation: A nurse uses a Doppler ultrasound device if pulses cannot be palpated for clients with thrombosis. Magnetic resonance imaging, radiography, and computed tomography scans are diagnostic tests to determine disorders of the endocrine, tumors, and so on.
Which of the following assessment results is considered a major risk factor for PAD? a) Cholesterol of 200 mg/dL b) LDL of 100 mg/dL c) Triglyceride level of 150 mg/dL d) BP of 160/110 mm Hg
d. BP of 160/110 mm Hg Explanation: Hypertension is considered a major risk factor for PAD. Blood pressure should be less than 130/90 mm Hg. The other laboratory results are within the recommended range of normal to high normal.
A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? a) Urine output of 15 ml/hour and 2+ hematuria b) Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute c) Urine output of 150 ml/hour and heart rate of 45 beats/minute d) Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute
d. Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute Explanation: Assessment findings that indicate possible bleeding or recurring dissection include hypotension with reflex tachycardia (as evidenced by a blood pressure of 82/40 mm Hg and a heart rate of 125 beats/minute), decreased urine output, and unequal or absent peripheral pulses. Hematuria, increased urine output, and bradycardia aren't signs of bleeding from aneurysm repair or recurring dissection.
Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity? a) Vertigo b) Acute limb ischemia c) Dizziness d) Intermittent claudication
d. Intermittent claudication Explanation: The hallmark symptom of PAD in the lower extremity is intermittent claudication. This pain may be described as aching or cramping in a muscle that occurs with the same degree of exercise or activity and is relieved with rest. Acute limb ischemia is a sudden decrease in limb perfusion, which produces new or worsening symptoms that may threaten limb viability. Dizziness and vertigo are associated with upper extremity arterial occlusive disease.
Aortic dissection may be mistaken for which of the following disease processes? a) Stroke b) Pneumothorax c) Angina d) Myocardial infarction (MI)
d. Myocardial infarction (MI) Explanation: Aortic dissection may be mistaken for an acute MI, which could confuse the clinical picture and initial treatment. Aortic dissection is not mistaken for stroke, pneumothorax, or angina. (
Which of the following tends to be prolonged on the electrocardiogram (ECG) during a first-degree atrioventricular (AV) block? a) T wave b) QRS c) P wave d) PR interval
d. PR interval Explanation: First-degree AV block occurs when atrial conduction is delayed through AV node resulting in a prolonged PR interval. The QRS complex, T wave, and P wave are not prolonged in first-degree AV block.
The most common site of aneurysm formation is in the: a) ascending aorta, around the aortic arch. b) aortic arch, around the ascending and descending aorta. c) descending aorta, beyond the subclavian arteries. d) abdominal aorta, just below the renal arteries.
d. abdominal aorta, just below the renal arteries. Explanation: About 75% of aneurysms occur in the abdominal aorta, just below the renal arteries (Debakey type I aneurysms). Debakey type II aneurysms occur in the aortic arch around the ascending and descending aorta, whereas Debakey type III aneurysms occur in the descending aorta, beyond the subclavian arteries.
