vascular disruption

arterial disease

cool pale skin, intermittent claudication, thick shiny nails, elevational pallor and dependent rubor in lower legs

d, e, f The nurse suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms? Select all that apply. a. Hypertension b. Tachycardia c. Bounding right pedal pulses d. Cold right foot e. Numbness and tingling of right foot f. Mottling of right foot and lower leg

d,e,f

pseudoaneursym

false blood leaks out into the wall, but BV remains intact.

The nurse is assessing a client with an ulcer for signs and symptoms of hemorrhage. The nurse interprets which condition as a sign/symptom of possible hemorrhage? 1. Hematemesis 2. Bradycardia 3. Hypertension 4. Polyuria

hematemesis

Which diagnostic test would be used first to evaluate a client with upper GI bleeding?

hemoglobin and hematocrit

A client has sudden, severe pain in the back and chest, accompanied by shortness of breath. The client describes the pain as a "tearing" sensation. The HCP suspects the client is experiencing a dissecting aortic aneurysm. The emergency supply cart is brought into the room because one complication of a dissecting aneurysm is 1. cardiac tamponade 2. stroke 3. pulmonary edema 4. myocardial infarction

1

A client with venous thrombus reports having pain in the legs. What should the nurse do first? 1. Elevate the foot of the bed 2. Elevate the legs of using a pillow under the knees 3. Encourage adequate fluid intake 4. Massage the lower legs

1

An abdominal x-ray report of an obese patient indicates a pulsatile mass in the periumbilical area. Further diagnostic tests confirm that the patient has an abdominal aortic aneurysm (> 6 cm). The nurse recognizes that aneurysms in the early phase are often difficult to diagnose for what reasons? Select all that apply. 1 Abdominal aortic aneurysms are often asymptomatic 2 Abdominal aortic aneurysms often go undetected by routine examinations 3 Abdominal aortic aneurysms can only be diagnosed by specialized equipment 4 Abdominal aortic aneurysms may mimic the symptoms of other diseases 5 Obesity might influence the results of abdominal x-rays

1,4,5

the patient with a rupturing abdominal aortic aneursym is at an increased risk for

hemorrhagic shock

what is the number one cause of AAA?

hypertension, athersclerosis, age, increased lipids

The nurse is assessing the lower extremities of the client with peripheral artery disease. Which findings are expected? Select all that apply. 1. hairy legs 2. mottled skin 3. pink skin 4. coolness 5. moist skin

2, 4

The nurse is caring for a patient in the recovery area following a femoral-posterior tibial bypass graft. Which interventions should the nurse perform for the patient? Select all that apply. 1 Take ankle-brachial index (ABI) measurement. 2 Obtain palpable pulses. 3 Check sensation and movement. 4 Inspect operative extremity every 15 minutes. 5 Place the patient in a knee-flexed position.

2,3,4

A client is admitted to the emergency department with severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. The primary goal at this time is to 1. maintain circulation 2. manage pain 3. prepare the client for emergency surgery 4. teach postoperative breathing exercises

3

One goal is caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. To achieve this goal, the nurse should encourage the client to: 1. avoid eating low-fat foods 2. elevate the legs above the heart 3. stop smoking 4. begin a jogging program

3

The nurse is assessing a client who had an abdominal aortic aneurysm repair 2 hrs ago. Which finding warrants further evaluation? 1. absent bowel sounds and mild abdominal distention 2. a BUN of 26 mg/dL and creatinine of 1.2 mg/dL 3. an arterial BP of 80/50 mm Hg 4. +1 pedal pulses in bilateral lower extremities

3

A client is admitted with acute pancreatitis. The nurse should monitor which laboratory values? 1. increased calcium level 2. decreased glucose level 3. decreased urine amylase level 4. increased serum amylase and lipase levels

4

continous bubbling in the water-seal compartment during inspiration and expiration indicates ___

AIR LEAK

The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site

ANS: B The large amount of blood may indicate that the patient is in danger of developing hypovolemic shock. An air leak would be expected immediately after chest tube placement for a pneumothorax. Initially, brisk bubbling of air occurs in this chamber when a pneumothorax is evacuated. The pain should be treated but is not as urgent a concern as the possibility of continued hemorrhage. Subcutaneous emphysema should be monitored but is not unusual in a patient with pneumothorax. A small amount of subcutaneous air is harmless and will be reabsorbed.

Thoracic Aneurysm

Balloon-like dilatation of the thoracic aorta result of traumatic accident related to hypertension close to hear makes it more difficult to clamp above and below it.

Which of the following signs indicates a chest tube may be removed? A. Drainage is approximately 100mL/hr in a patient with pleural chest tube following spinal surgery B. The chest radiograph shows only a small residual pneumothorax in a patient requiring mechanical ventilation C. Bubbling in the water seal has been absent for 24 hours following iatrogenic pneumothorax from CVP placement D. Fluctuations in the water seal are approximately 2 to 4cmH2O with each breathing cycle

C

Which client who has just arrived in the emergency department does the nurse classify as emergent and needing immediate medical evaluation? a. A 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness b. A 64-year-old with chronic venous ulcers who has a temperature of 100.1°F (37.8°C) c. A 69-year-old with a 40-pack-year cigarette history who is reporting foot numbness d. A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic

D

AAA treatment

Smoking cessation and BP control (beta-blockers). Can do an elective repair once it reaches *5.5cm*. Surgical resection or endovascular repair are both options.

symptoms of abdominal aortic aneurysm

abdominal mass/ridgitity, anxiety, clammy skin, rapid heart rate (upon standing up), pain in abdomen or back (pain is severe, sudden, persistent, or constant. The pain may radiate to groin, buttocks, or legs) pulsating sensation in abdomen

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

apply pressure to the site

Which descriptions are characteristic of hypoxemic respiratory failure (select all that apply)? a. Referred to as ventilatory failure b. Primary problem is inadequate O2 transfer c. Risk of inadequate O2 saturation of hemoglobin exists d. Body is unable to compensate for acidemia of increased PaCO2 e. Most often caused by ventilation-perfusion (V/Q) mismatch and shunt f. Exists when PaO2 is 60 mm Hg or less, even when O2 is administered at 60%

b,c,e,f

sacular

ballon outpouch

Abdominal Aortic Aneurysm

below kidneys, above bifurcation most common type of aneursym

A client is admitted to the health care facility with a diagnosis of a bleeding gastric ulcer. The nurse expects the client's stools to have which description? 1. Clay-colored 2. Coffee-ground-like 3. Black and tarry 4. Bright red

black and tarry

fusiform

most common and encompass entire vessel

A nurse is caring for a client with active upper GI bleeding. What is the appropriate diet for this client during the first 24 hours after admission? 1. Regular diet 2. Clear liquids 3. Skim milk 4. Nothing by mouth

nothing by mouth

PVD

pain is worse when standing or sitting elevating the legs eases pain and swelling

The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially?

respiratory alkalosis

TAA

thoracic aortic aneurysm symptoms: dyspnea, the result of pressure of the aneurysm sac against the trachea, a main bronchus, or the lung itself; cough, frequently paroxysmal and with a brassy quality; hoarseness, stridor, or weakness or complete loss of the voice (aphonia), resulting from pressure against the laryngeal nerve; and dysphagia (difficulty in swallowing) due to impingement on the esophagus by the aneurysm.

A clinically obese client with moderately painful varicose veins chooses self-care options for managing the variscosities. The nurse should coach the client to follow which healthcare practicies? Select all that apply 1. Lose weight 2. Wear compression stockings 3. Apply lotion to the veins 4. Elevate the legs 5. Sleep with pillows under the knees

1,2,4

Which instructions should be included in the plan of care for a client who had a left femoral-popliteal bypass yesterday? Select all that apply. 1. Turn frequently, and use pillows to support the incision 2. Encourage the client to change positions frequently to prevent atelectasis 3. Place the left leg in a knee-flexed position to promote oxygenation 4. Place the client in supine position, and elevate the leg above the heart to prevent edema. 5. Encourage the client to maintain bed rest to prevent stress on suture line.

1,2,5

The nurse is instructing a client who is at risk for peripheral artery disease how to use knee-length elastic stocking (support hose). What instructions should the teaching plan include? Select all that apply. 1. Apply the elastic stockings before getting out of bed. 2. Remove the stocking if swelling occurs. 3. Remove the stocking every 8 hrs, elevate the feet, and reapply in 15 mins. 4. Once the stocking have been pulled over the calf, roll the remaining stocking down to make a cuff. 5. Keep the stockings in place for 48 hrs, and reapply using a clean pair of stockings.

1,3