S3 N233 PrepU - Ch. 30: Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation

TEST 1

TEST 1

14. The nurse instructs a client with Raynaud phenomenon on actions to improve the symptoms. Which client statement indicates the need for additional instruction? "I will wear gloves when taking food out of the freezer." "I will limit the amount of cigarettes I smoke." "I will put on gloves before opening a cold car door." "I will avoid stressful situations."

"I will limit the amount of cigarettes I smoke." Explanation: Raynaud phenomenon is a form of intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of the fingertips or toes. Patients should avoid all forms of nicotine, which may induce attacks; this includes nicotine gum or patches used to aid smoking cessation. The client should be instructed to avoid situations that may be stressful as this could trigger an attack. Wearing gloves before opening a cold car door and when taking food out of the freezer should also be done as this could trigger vasoconstriction and an attack.

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 increase the amount of green leafy vegetables I eat to lower my cholesterol levels." "The older I get the higher my risk for peripheral arterial disease gets." "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." "Because my family is from Italy, I have a higher risk of developing peripheral arterial disease."

"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." Explanation: The use of tobacco products may be one of the most important risk factors in the development of atherosclerotic lesions. Nicotine in tobacco decreases blood flow to the extremities and increases heart rate and blood pressure by stimulating the sympathetic nervous system. This causes vasoconstriction, thereby decreasing arterial blood flow. It also increases the risk of clot formation by increasing the aggregation of platelets.

13. A client with peripheral arterial disease asks the nurse about using a heating pad to warm the feet. The nurse's best response is which of the following? "It is better to soak your feet in hot water as long as the water temperature is below 110 degrees F." "It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet." "A heating pad to your feet is fine as long as the temperature stays below 105 degrees F." "A heating pad to your feet is a good idea because it increases the metabolic rate."

"It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet." Explanation: It is safer to apply a heating pad to the abdomen, causing a reflex vasodilation in the extremities. Heat may be applied directly to ischemic extremities; however, the temperature of the heating source must not exceed body temperature. Excess heat may increase the metabolic rate of the extremities and increase the need for oxygen beyond that provided by the reduced arterial flow through the diseased artery.

2. A nurse is providing education about maintaining tissue integrity to a client with peripheral arterial disease. Which of the following statements by the client indicates a need for clarification? "I should apply powder daily because my feet perspire." "Shoes made of synthetic material are best for my feet." "It is important to apply sunscreen to the top of my feet when wearing sandals." "I can use lamb's wool between my toes if necessary." SUBMIT ANSWER

"Shoes made of synthetic material are best for my feet." Explanation: The client should wear leather shoes with an extra-depth toe box. Synthetic shoes do not allow air to circulate.

2. A nurse is providing education about maintaining tissue integrity to a client with peripheral arterial disease. Which of the following statements by the client indicates a need for clarification? "It is important to apply sunscreen to the top of my feet when wearing sandals." "I should apply powder daily because my feet perspire." "I can use lamb's wool between my toes if necessary." "Shoes made of synthetic material are best for my feet."

"Shoes made of synthetic material are best for my feet." Explanation: The client should wear leather shoes with an extra-depth toe box. Synthetic shoes do not allow air to circulate.

5. 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." "Enoxaparin will dissolve the clot, and warfarin will prevent any more clots from occurring." "Because of the potential for a pulmonary embolism, it is important for you to take at least two anticoagulants." "Administration of two anticoagulants decreases the risk of recurrent venous thrombosis."

"The enoxaparin will work immediately, but the warfarin takes several days to achieve 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 (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0).

20. 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? "If you feel any discomfort, stop and we will use a wheelchair to take you back to your room." "Walk to the point of pain, rest until the pain subsides, then resume ambulation." "If you feel pain during the walk, keep walking until the end of the hallway is reached." "As soon as you feel pain, we will go back and elevate your legs."

"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.

20. Heparin therapy is usually considered therapeutic when the activated partial thromboplastin time (aPTT) is how many times higher than a normal value? 0.5 to 1.5 1.5 to 2.5 2.5 to 3.5 3.5 to 4.5

1.5 to 2.5 Explanation: Heparin therapy is usually considered therapeutic when the aPTT is 1.5 to 2.5 times the normal aPTT value. The other values are not within therapeutic range.

18. The physician prescribed a Tegapore dressing to treat a venous ulcer. What should the nurse expect that the ankle-brachial index (ABI) will be if the circulatory status is adequate? 0.25 0.50 0.10 0.35

0.50 Explanation: After the circulatory status has been assessed and determined to be adequate for healing (ABI of more than 0.5) (Mosti, Iabichella, & Partsch, 2012), surgical dressings can be used to promote a moist environment.

1. 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. At least 12 hours. 2 to 3 days. The first 24 hours.

3 to 5 days. Explanation: It takes 3 to 5 days for a therapeutic international normalized ratio (INR) to be achieved. Therefore, Coumadin is given concurrently with heparin until a therapeutic level is established, usually within 72 hours.

15. Beginning warfarin concomitantly with heparin can provide a stable INR by which day of heparin treatment? 5 4 3 2

5 Explanation: Beginning warfarin concomitantly with heparin can provide a stable INR by day 5 of heparin treatment, at which time the heparin maybe discontinued.

9. 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? 20 30 40 50

50 Explanation: Typically, about 50% of the arterial lumen or 75% of the cross-sectional area must be obstructed before intermittent claudication is experienced.

11. The nurse explains to a patient that the primary cause of a varicose vein is: An incompetent venous valve. Phlebothrombosis. Venous occlusion. Venospasm.

An incompetent venous valve. Explanation: Varicose veins are abnormally dilated, tortuous, superficial veins caused by incompetent venous valves.

14. Which aneurysm occurs as a result of infection at arterial suture or graft sites? Saccular False Dissecting Anastomotic

Anastomotic Explanation: An anastomotic aneurysm occurs as a result of infection, arterial wall failure, and suture or graft failure. 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.

3. The nurse is assessing a client with severe hypertension. Which symptom indicates to the nurse that the client is experiencing dissection of the aorta? Pain when flexing the neck forward A ripping sensation in the chest Gradual onset of a frontal headache Numbness and pain of the left arm

A ripping sensation in the chest Explanation: Aortic dissections are commonly associated with poorly controlled hypertension. Dissection is caused by rupture in the intimal layer. A rupture may occur through adventitia or into the lumen through the intima, allowing blood to reenter the main channel and resulting in chronic dissection or occlusion of branches of the aorta. The onset of symptoms is usually sudden and described as severe, persistent pain that feels like tearing or ripping. An aortic dissection does not cause pain and numbness of the left arm. Pain when flexing the neck forward is not associated with an aortic dissection. An aortic dissection does not cause a headache.

19. The nurse is caring for a client recovering from surgery to treat aortoiliac disease. Which assessment findings indicate to the nurse that manual manipulation of the bowel occurred during the surgery? Select all that apply. Abdominal distention Liquid bowel movement Absence of bowel sounds Coffee-ground emesis Left lower quadrant pain

Abdominal distention Absence of bowel sounds Explanation: The treatment of aortoiliac disease is essentially the same as that for atherosclerotic PAD. If there is significant aortic disease, the surgical procedure of choice is the aortoiliac graft. If possible, the distal graft is anastomosed to the iliac artery, and the entire surgical procedure is performed within the abdomen. Because of this, abdominal assessment for bowel sounds and paralytic ileus is to be done at least every 8 hours. Abdominal distention and the absence of bowel sounds indicate paralytic ileus. Coffee-ground emesis is an indication of gastrointestinal bleeding which is not associated with surgery to treat aortoiliac disease. A liquid bowel movement may indicate bowel ischemia which is caused by an occlusion of the mesenteric blood supply. Left lower quadrant abdominal pain is not associated with treatment of aortoiliac disease.

6. Which of the following medications is considered a thrombolytic? Heparin Alteplase Lovenox Coumadin

Alteplase Explanation: Alteplase is considered a thrombolytic, which lyses and dissolves thrombi. Thrombolytic therapy is most effective when given within the first 3 days after acute thrombosis. Heparin, Coumadin, and Lovenox do not lyse clots.

2. 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: Reteplase. Urokinase. Streptokinase Alteplase.

Alteplase. Explanation: Alteplase has fewer disadvantages than the other thrombolytic agents. Refer to Table 18-2 in the text.

2. To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the: Anterior surface of the foot near the ankle joint. Outside of the foot just below the heel. Exterior surface of the foot near the heel. Inside of the ankle just above the heel.

Anterior surface of the foot near the ankle joint. Explanation: The dorsalis pedis pulse can be palpated on the dorsal surface of the foot distal to the major prominence of the navicular bone.

12. A client is being discharged home with a venous stasis ulcer on the right lower leg. Which topic will the nurse include in client teaching before discharge? Adequate carbohydrate intake Prophylactic antibiotic therapy Methods of keeping the wound area dry Application of graduated compression stockings

Application of graduated compression stockings Explanation: Graduated compression stockings usually are prescribed for clients with venous insufficiency. The required pressure gradient is determined by the amount and severity of venous disease. Graduated compression stockings are designed to apply 100% of the prescribed pressure gradient at the ankle and pressure that decreases as the stocking approaches the thigh, reducing the caliber of the superficial veins in the leg and increasing flow in the deep veins. These stockings may be knee high, thigh high, or pantyhose.

1. 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 Neither venous nor arterial Trauma Venous insufficiency

Arterial insufficiency Explanation: Characteristics of arterial insufficiency ulcers include location at the tips of the toes, extreme painfulness, and circular shape with pale to black ulcer bases. Ulcers caused by venous insufficiency will be irregular in shape, minimal pain if superficial (can be painful), and usually located around the ankles or the anterior tibial area.

10. 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? Ask about any changes in skin color that occur in response to cold. Attempt to palpate the dorsalis pedis and posterior tibial pulses. Assess for unilateral swelling and tenderness of either leg. Check for the presence of tortuous veins bilaterally on the legs.

Attempt to palpate the dorsalis pedis and posterior tibial pulses. Explanation: Intermittent claudication is a sign of peripheral arterial insufficiency. The nurse should assess for other clinical manifestations of peripheral arterial disease in a client who describes intermittent claudication. A thorough assessment of the client's skin color and temperature and the character of the peripheral pulses are important in the diagnosis of arterial disorders.

17. Which of the following assessment results is considered a major risk factor for PAD? Triglyceride level of 150 mg/dL LDL of 100 mg/dL Cholesterol of 200 mg/dL BP of 160/110 mm Hg

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.

3. Which of the following is a characteristic of an arterial ulcer? Brawny edema Border regular and well demarcated Edema may be severe Ankle-brachial index (ABI) > 0.90

Border regular and well demarcated Explanation: Characteristics of an arterial ulcer include a border that is regular and demarcated. Brawny edema, ABI > 0.90, and edema that may be severe are characteristics of a venous ulcer.

14. 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. Stress. Lack of exercise. Obesity.

Cigarette smoking. Explanation: Nicotine decreases blood flow, increases heart rate and blood pressure, and increases the risk for clot formation by increasing platelet aggregation. Smokers have a four-fold higher risk of developing pain from arterial disease than nonsmokers. Carbon monoxide, produced by burning tobacco, combines with hemoglobin more readily than oxygen, thus depriving tissues of oxygen.

11. Pentoxifylline (Trental) is a medication used for which of the following conditions? Claudication Thromboemboli Hypertension Elevated triglycerides

Claudication Explanation: Trental and Pletal are the only medications specifically indicated for the treatment of claudication. Thromboemboli, hypertension, and elevated triglycerides are not indications for using Trental.

4. The nurse assesses a patient with hip pain related to intermittent claudication. She knows that the area of arterial narrowing is the: Common iliac artery. Common femoral artery. Anterior tibial. Posterior tibial.

Common iliac artery. Explanation: The location of the claudication occurs in muscle groups distal to the diseased vessel. Hip or buttock pain may result from reduced blood flow from the common iliac artery.

13. The nurse is caring for a client recovering from acute axillary lymphangitis. Which treatment will the nurse anticipate being prescribed for this client after antibiotic therapy has concluded? Physical therapy Compression sleeve Arm sling Aspirin therapy

Compression sleeve Explanation: Lymphangitis is an acute inflammation of the lymphatic channels. It arises most commonly from a focal area of infection in an extremity caused by bacteria. At the conclusion of antibiotic therapy used for an acute attack, a graduated compression sleeve should be worn on the affected extremity for several months to prevent long-term edema. An arm sling is not required. The client will not need aspirin therapy as there is no surgery and/or risk of clots. The client will not need physical therapy as there should be no lingering effects from treatment of lymphangitis.

1. A health care provider wants a cross-sectional image of the abdomen to evaluate the degree of stenosis in a patient's left common iliac artery. The nurse knows to prepare the patient for which of the following? Angiography Magnetic resonance angiography (MRA) Doppler ultrasound Computed tomography angiography (CTA)

Computed tomography angiography (CTA) Explanation: A CTA is used to visualize arteries and veins and help assess for stenosis and occlusion.

3. Which of the following are indications of a rupturing aortic aneurysm? Select all that apply. Increasing hematocrit Decreasing blood pressure Increasing blood pressure Decreasing hematocrit Constant, intense back pain

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.

3. 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? Slow heart rate and high blood pressure Constant, intense headache and falling blood pressure Constant, intense back pain and falling blood pressure Higher than normal blood pressure and falling hematocrit

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.

7. 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? Aching, cramping pain Superficial ulcer Diminished or absent pulses Pulses that are present but difficult to palpate

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.

5. Which is a characteristic of arterial insufficiency? Superficial ulcer Pulses are present but may be difficult to palpate Diminished or absent pulses Aching, cramping pain

Diminished or absent pulses Explanation: A diminished or absent pulse is a characteristic of arterial insufficiency. Venous characteristics include superficial ulcer formation, an aching and cramping pain, and presence of pulses.

20. Which risk factor is related to venous stasis for deep vein thrombosis (DVT) and pulmonary embolism (PE)? Obesity Surgery Pacing wires Trauma

Obesity Explanation: Obesity is a risk factor for DVT and PE related to venous stasis. Trauma, pacing wires, and surgery are related to endothelial damage as a risk factor for DCAT and PE.

12. As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client? Assess for the sites of bleeding. Assess for skin integrity. Demonstrate how to apply and remove elastic support stockings. Demonstrate how to self-administer IV infusions.

Demonstrate how to apply and remove elastic support stockings. Explanation: The nurse demonstrates how to apply and remove elastic support stockings. Varicose veins do not require the nurse to demonstrate how to self-administer IV infusions. Varicose veins require the client to elevate legs regularly and perform leg exercises. However, it does not involve bleeding or skin lesions.

9. Which aneurysm results in bleeding into the layers of the arterial wall? Saccular False Dissecting Anastomotic

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.

14. 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 an hour. Elevate the legs periodically for at least 15 to 20 minutes. Avoid foods with iodine. Refrain from sexual activity for a week.

Elevate the legs periodically for at least 15 to 20 minutes. Explanation: The nurse should advise the client to periodically elevate the legs for at least 15 to 20 minutes. Avoiding foods with iodine or refraining from sexual activity for a week does not relate to venous insufficiency.

7. 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? Hydrocortisone (Solu-Cortef) Metoprolol (Lopressor) Epinephrine Cimetidine (Tagamet)

Epinephrine Explanation: Infrequently, a patient may have an immediate or delayed allergic reaction to the iodine contained in the contrast agent used in angiography. Manifestations include dyspnea, nausea and vomiting, sweating, tachycardia, and numbness of the extremities. Any such reaction must be reported to the interventionalist at once; treatment may include the administration of epinephrine, antihistamines, or corticosteroids.

11. Which statement is accurate regarding Raynaud disease? The disease generally affects the client trilaterally. It is most common in men 16 to 40 years of age. Episodes may be triggered by unusual sensitivity to cold. It affects more than two digits on each hand or foot. SUBMIT ANSWER

Episodes may be triggered by unusual sensitivity to cold. Explanation: Episodes of Raynaud disease may be triggered by emotional factors or by unusual sensitivity to cold. The disease is most common in women between 16 and 40 years of age. It is generally unilateral and affects only one or two digits.

16. Which class of medication lyses and dissolves thrombi? Fibrinolytic Factor XA inhibitors Platelet inhibitors Anticoagulant

Fibrinolytic Explanation: Thrombolytic (fibrinolytic) therapy lyses and dissolves thrombi in 50% of clients. Anticoagulants, platelet inhibitors, and factor XA inhibitors do not lyse or dissolve thrombi.

9. Which of the following are complications of percutaneous transluminal balloon angioplasty (PTA)? Select all that apply. Embolization Dissection of the vessel Bleeding Stent migration Hematoma

Hematoma Embolization Dissection of the vessel Bleeding Stent migration Explanation: PTA is used to treat artherosclerosis. A balloon-tipped catheter is maneuvered across the area of stenosis, and a stent (small mesh tube) may be inserted to support the blood vessel walls and prevent collapse. Complications from PTA include hematoma, embolization, dissection of the vessel, bleeding, intimal damage (dissection), and stent migration.

9. 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

Hemorrhage. Explanation: All choices are serious and require medical/surgical intervention. However, hemorrhage is the most serious complication that requires immediate attention

15. 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? Surgical debridement Hyperbaric oxygen Vacuum-assisted closure device Enzymatic debridement

Hyperbaric oxygen Explanation: Hyperbaric oxygenation (HBO) may be beneficial as an adjunct treatment in patients with diabetes with no signs of wound healing after 30 days of standard wound treatment. HBO is accomplished by placing the patient into a chamber that increases barometric pressure while the patient is breathing 100% oxygen. Treatment regimens vary from 90 to 120 minutes once daily for 30 to 90 sessions. The process by which HBO is thought to work involves several factors. The edema in the wound area is decreased because high oxygen tension facilitates vasoconstriction and enhances the ability of leukocytes to phagocytize and kill bacteria. In addition, HBO is thought to increase diffusion of oxygen to the hypoxic wound, thereby enhancing epithelial migration and improving collagen production.

4. The nurse is caring for a client with abdominal aortic aneurysm (AAA). Which assessment finding is most likely to indicate a dissection of the aneurysm? Severe pain Hypertensive crisis Rectal bleeding Hematemesis

Severe pain Explanation: Pressure from an enlarging or dissecting abdominal aortic aneurysm is likely to be exhibited as severe pain. A decrease in blood pressure will result as the client goes into shock from hemorrhaging. Blood in emesis or rectal bleeding is not associated with rupture of AAA.

3. 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 In 2 days Within 12 hours Within the first 24 hours

In 3 to 5 days 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 (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0) (Holbrook et al., 2012).

20. The nurse plans care for a client who is newly diagnosed with peripheral artery disease (PAD). For each nursing action, click to specify if the intervention is appropriate to increase the arterial blood supply to the client's extremities or to promote vasodilation and prevent vascular compression. Nursing Action. Increase Arterial Blood Supply to Extremities. Promote Vasodilation and Prevent Vascular Compression Wear warm clothing in the winter. Keep legs in a dependent position. Do not use of bicotine products. Increase in physical activity each day. Avoid crossing the legs.

Increase Arterial Blood Supply to the Extremities - Wear warm clothing in the winter. - Keep legs in a dependent position. Promote Vasodilation and Prevent Vascular Compression - Do not use of bicotine products. - Increase in physical activity each day. - Avoid crossing the legs. Explanation: Peripheral artery disease (PAD) is defined as arterial insufficiency of the extremities that occurs most often in men and is a common cause of disability. Appropriate nursing actions to increase arterial blood supply to the client's extremities include keeping the legs in a dependent position and encouraging physical activity. Keeping legs in a dependent position enhances arterial blood supply, while exercise promotes blood flow and the development of collateral circulation. Appropriate nursing actions to promote vasodilation and prevent vascular compression include wearing warm clothing when it is cold, discouraging the use of nicotine products, and advising the client to avoid crossing the legs. Warmth promotes arterial flow by preventing vasoconstriction from chilling; nicotine causes vasospasm, which decreases circulation; and crossing the legs causes compression of vessels with the subsequent impediment of circulation, resulting in venous stasis. Keeping warm, discouraging the use of nicotine products, and telling the client to avoid crossing the legs are nursing actions more appropriate to promote vasodilation and prevent vascular compression versus increasing arterial blood supply to the extremities. Keeping the legs in a dependent position and encouraging physical activity daily are interventions that increase arterial blood supply to the extremities versus promoting vasodilation and preventing vascular compression.

10. Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending? Elevated blood pressure and rapid respirations Retrosternal back pain radiating to the left arm Decreased pulse rate and blood pressure Increased abdominal and back pain

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.

14. A nurse is developing a nursing care plan for a client with peripheral arterial disease. Which of the following will be the priority nursing diagnosis? Ineffective thermoregulation Ineffective peripheral tissue perfusion Ineffective self-health management Impaired tissue integrity

Ineffective peripheral tissue perfusion Explanation: The goal is to increase arterial blood supply to the extremities; the priority nursing diagnosis is Ineffective peripheral tissue perfusion related to compromised circulation.

8. 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 Risk for injury related to edema Impaired gas exchange related to increased blood flow Excess fluid volume related to peripheral vascular disease

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.

16. 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? Prothrombin time (PT) is 0.5 times normal. K+ level is 3.5. Activated partial thromboplastin time (aPPT) is half of the control value International normalized ratio (INR) is 2.5.

International normalized ratio (INR) is 2.5. Explanation: Oral anticoagulants such as warfarin are monitored by 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 (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0)

19. Which observation regarding ulcer formation on the client's lower extremity indicates to the nurse that the ulcer is a result of venous insufficiency? Is deep, involving the joint space Though superficial, is very painful Base is pale to black Large and superficial

Large and superficial Explanation: Ulcerations are in the area of the medial or lateral malleolus (gaiter area) and are typically large, superficial, and highly exudative. Superficial venous insufficiency ulcers cause minimal pain. The base of a venous insufficiency ulcer shows a beefy red to yellow fibrinous color.

16. With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by: Placing the limb in a plane horizontal to the body. Massaging the limb after application of cold compresses. Lowering the limb so that it is dependent. Elevating the limb over the heart level.

Lowering the limb so that it is dependent. Explanation: Lowering the extremity to a dependent position improves perfusion to the distal tissues.

1. The nurse is caring for a client with upper extremity arterial disease. Which assessments will the nurse include in the client's plan of care? Select all that apply. Place the affected extremity in a dependent position. Assess capillary refill on both arms every 2 hours. Measure blood pressure on both arms. Compare radial pulses on both wrists every 2 hours. Encourage activities using the affected extremity.

Measure blood pressure on both arms. Assess capillary refill on both arms every 2 hours. Compare radial pulses on both wrists every 2 hours. Explanation: Arterial stenosis and occlusions occur less frequently in the upper extremities than in the legs, and cause less severe symptoms because the collateral circulation is significantly better in the arms. However symptoms of upper extremity arterial disease include arm fatigue and pain with exercise, the inability to hold or grasp objects, and possible difficulty driving. The assessment of this client includes measuring blood pressure on both upper extremities since there may be a difference of more than 15 to 20 mm Hg because of the arterial occlusion. Capillary refill should also be assessed every 2 hours along with comparing the radial pulses on both wrists every 2 hours. Activities using the affected upper extremity can cause cramping and pain. There is no evidence that the dependent position is helpful when caring for a client with upper extremity arterial disease.

12. 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? Very mild arterial insufficiency Moderate to severe arterial insufficiency Tissue loss to that foot No arterial insufficiency

Moderate to severe arterial insufficiency Explanation: Normal people without arterial insufficiency have an ABI of about 1.0. Those with an ABI of 0.95 to 0.5 have mild to moderate arterial insufficiency. Those with an ABI of less than 0.50 have ischemic rest pain. Those with tissue loss have severe ischemia and an ABI of 0.25 or less.

15. Aortic dissection may be mistaken for which of the following disease processes? Angina Stroke Myocardial infarction (MI) Pneumothorax

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.

12. The nurse is performing wound care for a patient with a necrotic sacral wound. The prescribed treatment is isotonic saline solution with fine mesh gauze and a dry dressing to cover. What type of debridement is the nurse performing? Nonselective debridement Surgical debridement Enzymatic debridement Selective debridement

Nonselective debridement Explanation: Nonselective débridement can be accomplished by applying isotonic saline dressings of fine mesh gauze to the ulcer. When the dressing dries, it is removed (dry), along with the debris adhering to the gauze. Pain management is usually necessary.

4. A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment? Redness, cool skin temperature, and swelling Numbness, cool skin temperature, and pallor Numbness, warm skin temperature, and redness Swelling, warm skin temperature, and drainage

Numbness, cool skin temperature, and pallor Explanation: Signs and symptoms of impaired circulation include numbness and cool, pale skin. Signs of localized infection may include swelling, drainage, redness, and warm skin. Signs of adequate circulation include normal sensation and warm skin with normal return of skin color after blanching.

15. 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. Massage the calf muscles if pain occurs. Keep the extremities elevated slightly. Use a heating pad to promote warmth.

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.

5. 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 Blood pressure every 2 hours Ankle-arm indices every 12 hours Color of the leg every 4 hours

Peripheral pulses every 15 minutes after 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 client's status remains stable.

6. 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 Plasma protein fraction Thrombin Phytonadione (vitamin K)

Protamine sulfate Explanation: Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn't given orally.) Thrombin is a hemostatic agent used to control local bleeding. Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it's used to treat clients who are in shock.

12. A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important? An active daily walking program History of increased aspirin use A history of diabetes mellitus Recent pelvic surgery

Recent pelvic surgery Explanation: The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes mellitus is a contributing factor associated with peripheral vascular disease.

4. 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? Increasing blood pressure and monitoring fluid intake and output Stabilizing heart rate and blood pressure and easing anxiety Decreasing blood pressure and increasing mobility Increasing blood pressure and reducing mobility

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.

9. 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? Increasing blood pressure and reducing mobility Decreasing blood pressure and increasing mobility Increasing blood pressure and monitoring fluid intake and output Stabilizing heart rate and blood pressure and easing anxiety

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.

5. Which of the following are alterations noted in Virchow's triad? Select all that apply. Vessel wall injury Stasis of blood Tenderness Altered coagulation Edema

Stasis of blood Vessel wall injury Altered coagulation Explanation: Three factors, known as Virchow's triad, are believed to play a significant role in the development of venous thrombosis. They are stasis of blood, vessel wall injury, and altered coagulation. Edema and tenderness are clinical manifestations of venous thrombosis, but are not part of the triad.

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

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.

16. 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. Do not cross your legs for more than 30 minutes at a time. Keep your feet elevated above your heart. Wear antiembolic stockings daily to assist with blood return to the heart.

Stop smoking. Explanation: Nicotine from tobacco products causes vasospasm and can thereby dramatically reduce circulation to the extremities. When the client elevates the feet above the heart level, the heart must work against gravity to supply blood to the feet. Antiembolic stocking are helpful for venous return to the heart, but constriction is not helpful for lack of arterial blood flow. Crossing the legs for more than a few minutes at a time compresses arteries and decreases blood supply to the legs and feet.

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13. 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 Engaging in anaerobic exercise Reducing daily fat intake to less than 45% of total calories Abstaining from foods that increase levels of high-density lipoproteins (HDLs)

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.

6. 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. The client is experiencing normal sensations associated with this condition. The client is experiencing inflammation of the aneurysm. The aneurysm has become obstructed.

The aneurysm may be preparing to rupture. Explanation: Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Abdominal pain is often localized to the middle or lower abdomen to the left of the midline. Low-back pain may be present because of pressure of the aneurysm on the lumbar nerves. Indications of a rupturing AAA include constant, intense back pain; falling blood pressure; and decreasing hematocrit. Rupture into the peritoneal cavity is quickly fatal. A retroperitoneal rupture of an aneurysm may result in hematomas in the scrotum, perineum, flank, or penis.

3. A pregnant client who developed deep vein thrombosis (DVT) in her right leg is receiving heparin I.V. on the medical floor. Physical therapy is ordered to maintain her mobility and prevent additional DVT. A nursing assistant working on the medical unit helps the client with bathing, range-of-motion exercises, and personal care. Which collaborative multidisciplinary considerations should the care plan address? The client is at risk for developing another DVT; therefore, the care plan should include reporting redness, tenderness, or edema in the other lower extremity. The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising. The client is pregnant and receiving I.V. heparin, placing her at risk for premature labor; therefore, the care plan should include reporting signs of premature labor. The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include sequential compression device application and strict bed rest.

The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising. Explanation: Feedback about possible bleeding and bruising from physical therapy and other caregivers should be incorporated into the care plan to ensure safety and optimal outcomes. Using a sequential compression device, mandating strict bed rest, and reporting signs of DVT don't incorporate collaborative care. Reporting signs of premature labor doesn't address the consequences of thrombocytopenia, which may occur with I.V. heparin therapy.

1. Which of the following is the most common site for a dissecting aneurysm? Cervical area Lumbar area Sacral area Thoracic area

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.

10. 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 Trauma Neither venous nor arterial insufficiency Arterial insufficiency

Venous insufficiency Explanation: Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gaiter 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.

18. Which client with a venous stasis ulcer is a candidate for topical hyperbaric oxygen therapy? a nonambulatory client a client whose ulcer includes necrotic tissue a client with an infected stasis ulcer a client with a chronic, nonhealing skin lesion

a client with a chronic, nonhealing skin lesion Explanation: Chronic, nonhealing skin lesions are treated with topical hyperbaric oxygen therapy. This approach delivers oxygen above atmospheric pressure directly to the wound rather than to the full body as with other disorders such as carbon monoxide poisoning. Necrotic tissue is debrided from a stasis ulcer. A client's infection is treated with an application of Silvadene, an antibacterial cream, or an antibiotic ointment and an occlusive transparent dressing such as Tegaderm that traps moisture and speeds healing.

17. The most common site of aneurysm formation is in the: abdominal aorta, just below the renal arteries. ascending aorta, around the aortic arch. descending aorta, beyond the subclavian arteries. aortic arch, around the ascending and descending aorta.

abdominal aorta, just below the renal arteries. Explanation: About 75% of aneurysms occur in the abdominal aorta, just below the renal arteries (Debarked type I aneurysms). Debarked type II aneurysms occur in the aortic arch around the ascending and descending aorta, whereas Debarked type III aneurysms occur in the descending aorta, beyond the subclavian arteries.

20. A client reports pain and cramping in the thigh when climbing stairs and numbness in the legs after exertion. Which diagnostic test with the physician likely perform right in the office to determine PAD? electron beam computed tomography photoplethysmography ankle-brachial index exercise electrocardiography

ankle-brachial index Explanation: The client's symptoms indicate possible peripheral artery disease (PAD). The ankle-brachial index is a simple, noninvasive test used for this diagnosis. An exercise electrocardiography may be ordered for a client with possible CAD. An EBCT is a radiologic test that produces x-rays of the coronary arteries using an electron beam. It is used to diagnose for CAD. Clients with suspected venous insufficiency will undergo photoplethysmography, a diagnostic test that measures light that is not absorbed by hemoglobin and consequently is reflected back to the machine.

17. 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 lymphoscintigraphy. contrast phlebography. air plethysmography. lymphangiography.

contrast phlebography. Explanation: Also known as venography, contrast phlebography involves injecting a radiopaque contrast agent into the venous system. If a thrombus exists, the x-ray image reveals an unfilled segment of vein in an otherwise completely filled vein. Air plethysmography quantifies venous reflux and calf muscle pump ejection. In lymphangiography, contrast media are injected into the lymph system. In a lymphoscintigraphy, a radioactive-labeled colloid is injected into the lymph system.

19. 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: reduces stress. increases high-density lipoprotein (HDL) level. aids in weight reduction. decreases venous congestion.

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.

5. 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: a 30-second filling time for the veins. elevational pallor. no rubor for 10 seconds after the maneuver. elevational rubor.

elevational pallor. Explanation: If arterial insufficiency is present, elevation of the limb would yield a pallor from the lack of circulation. Rubor on elevation and increased venous filling time would suggest venous problems secondary to venous trapping and incompetent valves.

13. 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. elevating the extremity to prevent pooling of blood. encouraging ambulation to prevent pooling of blood. providing warmth to the extremity.

forcing blood into the deep venous system. Explanation: Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn't a function of the stockings. Antiembolism stockings could possibly provide warmth, but this factor isn't how they prevent DVT. Elevating the extremity decreases edema but doesn't prevent DVT.

18. 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: place a heating pad around the affected calf. elevate the affected leg as high as possible. keep the affected leg level or slightly dependent. shave the affected leg in anticipation of surgery.

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.

1. Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect: loss of hair on the lower portion of the left leg. pallor and coolness of the left foot. left calf circumference 1" (2.5 cm) larger than the right. a decrease in the left pedal pulse.

left calf circumference 1" (2.5 cm) larger than the right. Explanation: Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased pulse, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT.