Chapter 26: Assessment and management of patients with vascular disorders and disorders of peripheral circulation

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.

Which of the following is the most effective intervention for preventing progression of vascular disease? Risk factor modification Avoid trauma Wear sturdy shoes Use neutral soaps

Risk factor modification

What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue? Evident scarring Ulcers and infection in the edematous area Loose and wrinkled skin Cyanosis

Ulcers and infection in the edematous area

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? "Administration of two anticoagulants decreases the risk of recurrent venous thrombosis." "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." "The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect."

"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? "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." "If you feel any discomfort, stop and we will use a wheelchair to take you back to your room." "If you feel pain during the walk, keep walking until the end of the hallway is reached."

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

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? "A heating pad to your feet is fine as long as the temperature stays below 105 degrees F." "It is better to soak your feet in hot water as long as the water temperature is below 110 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."

"\"It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet."

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

5

Approximately what percentage of the arterial lumen must be obstructed before intermittent claudication is experienced? 20 30 40 50

50

In a client with a bypass graft, the distal outflow vessel must have at least what percentage patency for the graft to remain patent? 20 30 40 50

50

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

Alteplase

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

Anterior surface of the foot near the ankle joint.

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

Constant, intense back pain and falling blood pressure

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

Diminished or absent pulsesp

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

Elevate the legs periodically for at least 15 to 20 minutes.

which class of medication lyses and dissolves thrombi? Fibrinolytic Platelet inhibitors Factor XA inhibitors Anticoagulant

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 Vacuum-assisted closure device Enzymatic debridement Surgical debridement

Hyperbaric oxygen

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

MI

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? Rectal bleeding Hypertensive crisis Severe pain Hematemesis

Severe pain

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

Stasis of bloodVessel wall injuryAltered coagulation

The most important factor regulating the caliber of blood vessels, which determines resistance to flow, is: Hormonal secretion. The influence of circulating chemicals. Independent arterial wall activity. The sympathetic nervous system.

The sympathetic nervous system.

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. Coffee-ground emesis Left lower quadrant pain Abdominal distention Liquid bowel movement Absence of bowel sounds

abdominal distention and 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.

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? exercise electrocardiography electron beam computed tomography ankle-brachial index photoplethysmography

ankle-brachial index

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 contrast phlebography. lymphangiography. air plethysmography. lymphoscintigraphy.

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.

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. lymphangiography. air plethysmography. contrast phlebography.

contrast phlebography. Explanation: When a thrombus exists, an x-ray image will disclose an unfilled segment of a 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

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

elevational pallor.

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

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.

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

keep the affected leg level or slightly dependent.

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: left calf circumference 1" (2.5 cm) larger than the right. a decrease in the left pedal pulse. pallor and coolness of the left foot. loss of hair on the lower portion of the left leg.

left calf circumference 1" (2.5 cm) larger than the right.

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

An incompetent venous valve.

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." "I walk only to the mailbox in my bare feet." "I stopped smoking and use only chewing tobacco." "I like to soak my feet in the hot tub every day."

"I have my wife look at the soles of my feet each day." Explanation: A client with peripheral vascular disease should examine his feet daily for redness, dryness, or cuts. If a client isn't able to do this examination on his own, then a caregiver or family member should help him. A client with peripheral vascular disease should avoid hot tubs because decreased sensation in the feet may make him unable to tell if the water is too hot. The client should always wear shoes or slippers on his feet when he is out of bed to help minimize trauma to the feet. Any type of nicotine, whether it's from cigarettes or smokeless tobacco, can cause vasoconstriction and further decrease blood supply to the extremities.

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 can use lamb's wool between my toes if necessary." "It is important to apply sunscreen to the top of my feet when wearing sandals." "Shoes made of synthetic material are best for my feet." "I should apply powder daily because my feet perspire."

"Shoes made of synthetic material are best for my feet."

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 0.10 0.50 0.35

0.50Explanation: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.

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

When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of: 2.5 to 3.0 times the baseline control. 3.5 times the baseline control. 4.5 times the baseline control. 1.5 to 2.5 times the baseline control.

1.5 to 2.5 times the baseline control.

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.

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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: Streptokinase Reteplase. Urokinase. Alteplase.

Alteplase.

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

An incompetent venous valve.

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? 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. Ask about any changes in skin color that occur in response to cold.

Attempt to palpate the dorsalis pedis and posterior tibial pulses.

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: Lack of exercise. Stress. Obesity. Cigarette smoking.

Cigarette smoking.

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

Claudication

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.

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? Arm sling Compression sleeve Physical therapy Aspirin therapy

Compression sleeve

Which term refers to enlarged, red, and tender lymph nodes? Elephantiasis Lymphadenitis Lymphangitis Lymphedema

Lymphadenitis

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

Demonstrate how to apply and remove elastic support stockings.

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

Dissecting

A patient who had a colon resection 3 days ago is complaining of discomfort in the left calf. How should the nurse assess Homan's sign to determine if the patient may have a thrombus formation in the leg? Lower the patient's legs and massage the calf muscles to note any areas of tenderness. Dorsiflex the foot while the leg is elevated to check for calf pain. Elevate the patient's legs for 20 minutes and then lower them slowly while checking for areas of inadequate blood return. Extend the leg, plantar flex the foot, and check for the patency of the dorsalis pedis pulse.

Dorsiflex the foot while the leg is elevated to check for calf pain.

The nurse is preparing a teaching tool about the development of a venous thromboembolism. Which information about Virchow triad will the nurse include? Select all that apply. Altered coagulation Prominent veins Edematous extremity Endothelial damage Venous stasis

Endothelial damage, Altered coagulation, Venous stasis

A client with peripheral artery disease (PAD) has limited access to supervised exercise therapy (SET). Which recommendation will the nurse make to help the client's intermittent claudication? Engage in an unsupervised walking program. Sleep with the legs in a horizontal position. Take an aspirin before going to bed at night. Elevate the lower extremities several times during the day.

Engage in an unsupervised walking program.

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

Epinephrine

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.

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.

A client with lower extremity edema is diagnosed with lymphedema. For which medication will the nurse prepare teaching for this client? Amoxicillin Heparin Oxycodone Furosemide

Furosemide

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. Stent dislodgement. Decreased motor function. Thrombosis of the graft.

Hemorrhage.

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

Hyperbaric oxygen

A client is recovering from sclerotherapy to treat varicose veins. Which information will the nurse provide to the client after the procedure? Select all that apply. Increase the amount of time walking at home. Take acetaminophen as prescribed for pain. Expect a burning sensation in the injected areas for 1 to 2 days. Wear graduated compression stockings for a week after the procedure. Change the dressings once a day.

Increase the amount of time walking at home. Take acetaminophen as prescribed for pain. Expect a burning sensation in the injected areas for 1 to 2 days. Wear graduated compression stockings for a week after the procedure.

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

Increased abdominal and back pain

A home health nurse is teaching a client with peripheral arterial disease ways to improve circulation to the lower extremities. The nurse encourages which of the following in teaching? Keeping the legs in a neutral or dependent position Application of ace wraps from the toe to below the knees Elevation of the legs above the heart Use of antiembolic stockings

Keeping the legs in a neutral or dependent position

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 Tissue loss to that foot Moderate to severe arterial insufficiency No arterial insufficiency

Moderate to severe arterial insufficiency

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

Obesity

A patient with impaired renal function is scheduled for a multidetector computer tomography (MDCT) scan. What preprocedure medication may the nurse administer to this patient? Epinephrine Dipyridamole (Persantine) Oral N-acetylcysteine Oral iodine

Oral N-acetylcysteine

A client who is diagnosed with Raynaud syndrome reports cold and numbness in the fingers. Which finding should the nurse identify as an early sign of vasoconstriction? Pallor Cyanosis Gangrene Ulceration

Pallor

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? Plasma protein fraction Thrombin Phytonadione (vitamin K) Protamine sulfate

Protamine sulfate

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? Thrombin Plasma protein fraction Phytonadione (vitamin K) Protamine sulfate

Protamine sulfate

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? Platelet count Prothrombin time (PT) Partial thromboplastin time (PTT) Bleeding time

Prothrombin time (PT

A client with systemic lupus erythematosus (SLE) complains that his hands become pale, blue, and painful when exposed to the cold. What disease should the nurse cite as an explanation for these signs and symptoms? Buerger's disease Peripheral vascular disease Arterial occlusive diseases Raynaud's disease

Raynaud's disease Explanation: Raynaud's disease results from reduced blood flow to the extremities when exposed to cold or stress. It's commonly associated with connective tissue disorders such as SLE. Signs and symptoms include pallor, coldness, numbness, throbbing pain, and cyanosis. Peripheral vascular disease results from a reduced blood supply to the tissues. It occurs in the arterial or venous system. Build-up of plaque in the vessels or changes in the vessels results in reduced blood flow, causing pain, edema, and hair loss in the affected extremity. Arterial occlusive disease is the obstruction or narrowing of the lumen of the aorta and its major branches that interrupts blood flow to the legs and feet, causing pain and coolness. Buerger's disease is an inflammatory, nonatheromatous occlusive disease that causes segmental lesions and subsequent thrombus formation in arteries, resulting in decreased blood flow to the feet and legs.

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? History of increased aspirin use Recent pelvic surgery An active daily walking program A history of diabetes mellitus

Recent pelvic surgery

Which of the following is the most effective intervention for preventing progression of vascular disease? Risk factor modification Wear sturdy shoes Avoid trauma Use neutral soaps

Risk factor modification Explanation: Risk factor modification is the most effective intervention for preventing progression of vascular disease. Measures to prevent tissue loss and amputation are a high priority. Patients are taught to avoid trauma; wear sturdy, well-fitting shoes or slippers; and use pH neutral soaps and body lotions.

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

Stop smoking.

What should the nurse do to manage persistent swelling in a client with severe lymphangitis and lymphadenitis? Avoid elevating the area. Inform the physician if the client's temperature remains low. Offer cold applications to promote comfort and to enhance circulation. Teach the client how to apply a graduated compression stocking.

Teach the client how to apply a graduated compression stocking.

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 Avoid elevating the area Offer cold applications to promote comfort and to enhance circulation Inform the physician if the client's temperature remains low

Teach the client how to apply an elastic sleeve

A nurse and physician are preparing to visit a hospitalized client with peripheral arterial disease. As you approach the client's room, the physician asks if the client has reported any intermittent claudication. The client has reported this symptom. The nurse explains to the physician which of the following details? The client experiences shortness of breath after walking about 50 feet. The client's legs awaken him during the night with itching. The client's fingers tingle when left in one position for too long. The client can walk about 50 feet before getting pain in the right lower leg.

The client can walk about 50 feet before getting pain in the right lower leg.

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

Thoracic area

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? Neither venous nor arterial insufficiency Trauma Venous insufficiency Arterial insufficiency

Venous insufficiency

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 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." "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."

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

client with a history of aching leg pain seeks medical attention for the development of a leg wound. Which assessment findings indicate to the nurse that the client is experiencing a venous ulcer? Select all that apply. Wound has an irregular border Thick, tough skin around the ankles Darkened skin around the lower extremities Wound is superficial Wound base is pale in color

Wound is superficialWound has an irregular borderThick, tough skin around the anklesDarkened skin around the lower extremities