260 Vascular PrepU

A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures?

"I have my wife look at the soles of my feet each day."

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."

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?

"Walk to the point of pain, rest until the pain subsides, then resume ambulation."

Heparin therapy is usually considered therapeutic when the activated partial thromboplastin time (aPTT) is how many times higher than a normal value?

2 to 2.5

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

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?

Attempt to palpate the dorsalis pedis and posterior tibial pulses.

Which of the following assessment results is considered a major risk factor for PAD?

BP of 160/110 mm Hg

Which class of medication lyses and dissolves thrombi?

Fibrinolytic

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?

Hyperbaric oxygen

Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending?

Increased abdominal and back pain

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?

International normalized ratio (INR) is 2.5

With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by:

Lowering the limb so that it is dependent

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?

Moderate to severe arterial insufficiency

A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs?

Prothrombin time (PT)

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?

Recent pelvic surgery

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 back pain

What should the nurse do to manage the persistent swelling in a client with severe lymphangitis and lymphadenitis?

Teach the client how to apply an elastic sleeve

The most common site of aneurysm formation is in the:

abdominal aorta, just below the renal arteries

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:

keep the affected leg level or slightly dependent