med surg 2.1 (original)

v

Arterial or Venous disease? Brown pigmentation of the legs

a

Arterial or Venous disease? Decreased peripheral pulses

v

Arterial or Venous disease? Dull ache in calf or thigh

v

Arterial or Venous disease? Edema around the ankles

v

Arterial or Venous disease? Heavy ulcer drainage

a

Arterial or Venous disease? Pallor on elevation of the legs

a

Arterial or Venous disease? Paresthesia

v

Arterial or Venous disease? Pruritis

a

Arterial or Venous disease? Thickened, brittle nails

v

Arterial or Venous disease? Ulceration around the medial malleolus

a

Arterial or Venous disease? Ulcers over bony prominences on toes and feet

b (Compression stockings are applied with the legs elevated to reduce pressure in the lower legs.Walking is recommended to prevent recurrent varicosities. Sitting and standing are both risk factors for varicose veins and venous insufficiency. An aspirin a day is not adequate to preventvenous thrombosis and would not be recommended to the patient who had just hadsclerotherapy)

A 42-year-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Before discharging the patient, the nurse teaches the patient that A. sitting at the work counter, rather than standing, is recommended. B. compression stockings should be applied before getting out of bed. C. exercises such as walking or jogging cause recurrence of varicosities. D. taking one aspirin daily will help prevent clotting around venous valves.

a (Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with Buerger's disease. Other therapies have limited success in treatment of this disease.)

A 46-year-old is diagnosed with thromboangiitis obliterans (Buerger's disease). When the nurse is planning expected outcomes for the patient, which outcome has the highest priority for this patient? A. Cessation of smoking B. Control of serum lipid levels C. Maintenance of appropriate weight D. Demonstration of meticulous foot care

c (Significant risk factors for peripheral artery disease include tobacco use, hyperlipidemia, elevated levels of high-sensitivity C-reactive protein, diabetes mellitus, and uncontrolled hypertension; the most important is tobacco use. Other risk factors include family history, hypertriglyceridemia, hyperuricemia, increasing age, obesity, sedentary lifestyle, and stress.)

A 50yr old woman weighs 85 kg and has a history of cigarette smoking, high blood pressure, high sodium intake, and sedentary lifestyle. When developing an individualized care plan for her, the nurse determines that the most important risk factors for peripheral artery disease (PAD) that need to be modified are: A. weight and diet B. activity level and diet C. cigarette smoking and high blood pressure D. sedentary lifestyle and high blood pressure

d (A pulmonary embolism is the most common complication of hip surgery because of high vascularity and the release of fat cells from the bone marrow)

A 72 yr old male client has a total hip replacement for long-standing degenerative bone disease of the hip. When assessing this client postoperatively, the nurse considers that the most common complication of hip surgery is: A. Pneumonia B. Hemorrhage C. Wound Infection D. Pulmonary Embolism

a

A ________ aneurysm may be surgically treated by excising only the weakened area and suturing the artery closed. A. saccular B. synthetic graft C. all D. iliac E. endovascular graft f. renal

a (Patients on anticoagulants should be taught to monitor and report any signs of bleeding, which can be a serious complication. Other important patient teaching includes reduction of vitamin K intake and routine coagulation laboratory studies if taking warfarin.)

A key aspect of teaching for the patient on anticoagulant therapy includes which instructions? A. monitor for and report any signs of bleeding B. do not take acetaminophen for a headache C. decrease your dietary intake of foods containing vitamin K D. arrange to have your blood drawn regularly to check drug levels

a (Rationale: The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud's phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness point to deep vein thrombosis, DVT)

A patient at the clinic says, "I have always taken an evening walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." The nurse should A. attempt to palpate the dorsalis pedis and posterior tibial pulses. B. check for the presence of tortuous veins bilaterally on the legs. C. ask about any skin color changes that occur in response to cold. D. assess for unilateral swelling, redness, and tenderness of either leg.

b (Rationale: Three important factors, called Virchow's triad, in the etiology of venous thrombosis are, 1, venous stasis, 2, damage of the endothelium, inner lining of the vein, and, 3, hypercoagulability of the blood. The patient at risk for venous thrombosis usually has predisposing conditions for these three disorders, see Table 38-7. The 32-year-old woman has the highest risk: long trips without adequate exercise, venous stasis, cigarette smoking, and use of oral contraceptives (especially in women older than 35 years who smoke, the likelihood of hypercoagulability of blood is increased.)

A patient at the highest risk for venous thromboembolism, VTE, is: A. a 62 year old man with spider veins who is having arthroscopic knee surgery B. a 32 year old woman who smokes, takes oral contraceptives, and is planning a trip to Europe C. a 26 year old woman who is 3 days postpartum and received maintenance IV fluid for 12 hours during her labor D. an active 72 year old man at home recovering from transuerthral resection of the prostate for benign prostatic hyperplasia

b (Rationale: Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the esophagus. Abdominal tenderness or changes in bowel habits are consistent with an abdominal aneurysm. Dizziness or weakness may occur if there is blood loss from the aneurysm, but this aneurysm was discovered accidentally, not because the patient was symptomatic.)

A patient has a 5-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining a nursing history from the patient, it will be most important to ask about A. back or lumbar pain. B. difficulty swallowing. C. abdominal tenderness. D. changes in bowel habits.

c (Rationale: A patient with a venous ulcer should have a balanced diet with adequate protein, calories, and micronutrients; this type of diet is essential for healing. Nutrients most important for healing include protein, vitamins A and C, and zinc. Foods high in protein, e.g., meat, beans, cheese, tofu;vitamin A, green leafy vegetables; vitamin C; citrus fruits, tomatoes, cantaloupe, and zinc; meat, seafood; must be provided. For patients with diabetes mellitus, maintaining normal blood glucose levels assists the healing process. For overweight individuals and no active venous ulcer, a weight-loss diet should be considered.)

A patient has a venous ulcer related to chronic venous insufficiency. The nurse should provide education on which type of diet for this patient? A.1200-calorie-restricted diet B. High-carbohydrate diet C. High-protein diet D. Low-fat diet

b (Rationale: To prevent hip flexion contractures, patients should lie on their abdomen for 30 minutes three or four times each day and position the hip in extension while prone. Patients should avoid sitting in a chair for more than 1 hour with hips flexed or having pillows under the surgical extremity. The patient should avoid dangling the residual limb over the bedside to minimize edema.)

A patient has an amputation of the left leg below the knee. Which intervention should the nurse include in the plan of care for this patient? a. Elevate the residual limb on a pillow for 4 to 5 days after surgery. b. Lay prone with hip extended for 30 minutes four times per day. c. Dangle the residual limb for 20 to 30 minutes every 6 hours. d. Sit in a chair for 1 to 2 hours three times each day.

d (Rationale: Intermittent claudication is an ischemic muscle ache or pain that is precipitated by a consistent level of exercise, resolves within 10 minutes or less with rest, and is reproducible. Angina is the term used to describe chest pain. Paresthesia is the term used to describe numbness or tingling in the toes or feet. Reactive hyperemia is the term used to describe redness of the foot; if the limb is in a dependent position the term is dependent rubor.)

A patient has peripheral artery disease. Which symptom, if experienced by the patient, indicates to the nurse that the patient is experiencing intermittent claudication? A. Patient complains of chest pain with strenuous activity B. Patient has numbness and tingling of the toes and feet C. Patient states the feet become red if in a D. Patient reports muscle leg pain that occurs with exercise

a (current research indicates that statin use by patients with PAD improves multiple outcomes. There is no research that supports the use of the other medication categories in PAD.)

A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which medication category will the nurse plan to include when providing patient teaching about PAD management? A. Statins B. Vitamins C. Thrombolytics D. Anticoagulants

b (The clinical manifestations of a ruptured abdominal aortic aneurysm include severe back pain, back or flank ecchymosis, Grey Turner's sign, and hypovolemic shock, tachycardia, hypotension, pale clammy skin, decreased urine output, altered level of consciousness, and abdominal tenderness.)

A patient is admitted to the hospital with a diagnosis of abdominal aortic aneurysm. which of the following S/S would suggest that his aneurysm has ruptured? A. sudden shortness of breath and hemoptysis B. sudden, severe low back pain and bruising along his flank C. gradually increasing substernal chest pain and diaphoresis D. sudden, patchy blue mottling on his feet and toes and rest pain

a (Because the edema associated with venous insufficiency increases when the patient has beenstanding, shoes will feel tighter at the end of the day. The other patient statements arecharacteristic of peripheral artery disease, PAD.)

A patient is admitted to the hospital with a diagnosis of chronic venous insufficiency. Which of these statements by the patient is most consistent with the diagnosis? A. "I can't get my shoes on at the end of the day." B. "I can never seem to get my feet warm enough." C. "I wake up during the night because my legs hurt." D. "I have burning leg pains after I walk three blocks."

b (Rationale: Unfractionated heparin can be given by continuous intravenous, IV, for VTE treatment. When given IV, heparin requires frequent laboratory monitoring of clotting status as measured by activated partial thromboplastin time, aPTT.)

A patient is admitted with venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory test should the nurse assess while the patient is receiving this medication? A. International normalized ratio (INR) B. Activated partial thromboplastin time (APTT) C. Anti-factor Xa D. Platelet count

c (Secondary Raynaud's phenomenon may occur in conjunction with autoimmune diseases such as rheumatoid arthritis, and patients should be screened for autoimmune disorders. Raynaud's phenomenon is not associated with hyperlipidemia, hypertension, or coronary artery disease.)

A patient tells the health care provider about experiencing cold, numb fingers when running during the winter and is diagnosed with Raynaud's phenomenon. The nurse will anticipate teaching the patient about tests for A. hypertension. B. hyperlipidemia. C. autoimmune disorders. D. coronary artery disease.

b (The nurse should monitor for hemorrhage after the surgery. The prosthesis will not be removed. To avoid flexion contracture of the hip, the leg will not be elevated on a pillow. The patient is placed in a prone position after amputation to prevent hip flexion, but this would not be done during the immediate postoperative period.)

A patient undergoes a right above-the-knee amputation with an immediate prosthetic fitting. When the patient first arrives on the orthopedic unit after surgery, the nurse should A. place the patient in a prone position. B. check the surgical site for hemorrhage. C. remove the prosthesis and wrap the site. D. keep the residual leg elevated on a pillow.

b (The patient should avoid sitting for long periods because of the increased stress on the suture linecaused by leg edema and because of the risk for venous thromboembolism (VTE). The otheractions by the LPN/LVN are appropriate)

A patient who has had a femoral-popliteal bypass graft to the right leg is being cared for on the surgical unit. Which action by an LPN/LVN caring for the patient requires the RN to intervene? A. The LPN/LVN places the patient in a Fowler's position for meals. B. The LPN/LVN has the patient sit in a bedside chair for 90 minutes. C. The LPN/LVN assists the patient to ambulate 40 feet in the hallway. D. The LPN/LVN administers the ordered aspirin 160 mg after breakfast.

b (Raynaud's phenomenon is an episodic vasospastic disorder of small cutaneous arteries, most frequently involving the fingers and toes. Diltiazem, Cardizem, is a calcium channel blocker that will relax smooth muscles of the arterioles by blocking the influx of calcium into the cells, thus reducing the frequency and severity of vasospastic attacks. There will be improved perfusion to the fingertips and a reduction of the vasospastic attacks.)

A patient with Raynaud's phenomenon is prescribed diltiazem (Cardizem). To evaluate the patient's response to this medication, what is most important for the nurse to assess in this patient? A. Increased prothrombin time (PT) B. Improved perfusion to distal fingers C. Increased mean arterial pressure D. Increased capillary refill time

a (Although most initial treatment for aortic dissection involves a period of lowering the BP and myocardial contractility to diminish the pulsatile forces in the aorta, immediate surgery is indicated when complications, such as occlusion of the carotid arteries, occur. Anticoagulants would prolong and intensify the bleeding, and blood is administered only if the dissection ruptures)

A patient with a dissection of the arch of the aorta has a decreased LOC and weak carotid pulses. The nurse anticipates that initial treatment of the patient will include... A. immediate surgery to replace the torn area with a graft B. administration of anticoagulants to prevent embolization C. administration of packed red blood cells (RBCs) to replace blood loss D. administration of antihypertensives to maintain a mean arterial pressure of 70-80 mmHG

a (Since the patient appears to be experiencing aortic dissection, the nurse's first action should be to determine the hemodynamic status by assessing blood pressure. The other actions also may be done, but they will not provide information that will determine what interventions are needed immediately for this patient.)

A patient with a history of an abdominal aortic aneurysm is admitted to the emergency department (ED) with severe back pain and absent pedal pulses. Which action should the nurse take first? A. Obtain the blood pressure. B. Ask the patient about tobacco use. C. Draw blood for ordered laboratory testing. D. Assess for the presence of an abdominal bruit.

b (Control hypertension with prescribed therapy, because Increased systolic BP continually puts pressure on the diseased area of the artery, promoting its expansion. Small aneurysms can be treated by decreasing BP, modifying atherosclerosis risk factors, and monitoring the size of the aneurysm.)

A patient with a small AAA is not a good surgical candidate. The nurse teaches the patient that one of the best ways to prevent expansion of the lesion is to A. Avoid strenous physical activity B. Control hypertension with prescribed therapy C. Comply with prescribed anticoagulant therapy D. Maintain a low-calcium diet to prevent calcification fo the vessel

c (Low molecular weight heparin, LMWH, is used because of the immediate effect on coagulationand discontinued once the international normalized ratio, INR, value indicates that the warfarin has reached a therapeutic level. LMWH has no thrombolytic properties. The use of two anticoagulants is not related to the risk for pulmonary embolism, and two are not necessary to reduce the risk for another VTE.)

A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is accurate? A. "Administration of two anticoagulants reduces the risk for recurrent venous thrombosis." B. "Lovenox will start to dissolve the clot, and Coumadin will prevent any more clots from occurring." C. "The Lovenox will work immediately, but the Coumadin takes several days to have an effect on coagulation." D. "Because of the potential for a pulmonary embolism, it is important for you to have more than one anticoagulant."

c

A patient with chronic arterial disease has a brachial SBP of 132 mm Hg and an ankle SBP of 102 mm Hg. The ankle-brachial index is ______ and indicates _______ (mild/moderate/severe) arterial disease. A. intermittent claudication B. non-healing ischemic ulcers and gangrene C. 0.77; mild D. rest

d (The patient's history and clinical manifestations are consistent with acute arterial occlusion, and resting the leg will decrease the oxygen demand of the tissues and minimize ischemic damage until circulation can be restored. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the leg.)

A patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. The nurse should notify the health care provider and A. elevate the left leg on a pillow. B. apply an elastic wrap to the leg. C. assist the patient in gently exercising the leg. D. keep the patient in bed in the supine position.

c (Rationale: The patient has potentially developed acute arterial ischemia, sudden interruption in the arterial blood supply to the extremity, caused by an embolism from a cardiac thrombus that occurred as a complication of infective endocarditis. Clinical manifestations of acute arterial ischemia include pain, pallor, paralysis, pulselessness, paresthesia, and poikilothermia. Without immediate intervention, ischemia may progress quickly to tissue necrosis and gangrene within a few hours. If the nurse detects these signs, the physician should be notified immediately.)

A patient with infective endocarditis develops sudden sudden left leg pain with pallor, paresthesia, and a loss of peripheral pulses. The nurse's initial action should be to: A. elevate the leg to promote venous return B. start anticoagulant therapy with IV heparin C. notify the physician of the change in peripheral perfusion D. place the bed in reverse Trandelelbrug to promote perfusion

1 (Rationale: Peripheral neuropathy is caused by diminished perfusion to neurons and results in loss of both pressure and deep pain sensations. The patient may not notice lower extremity injuries. Neuropathy increases susceptibility to traumatic injury and results in delay in seeking treatment.)

A patient with peripheral vascular disease has marked peripheral neuropathy. An appropriate nursing diagnosis for the patient is 1. risk for injury related to decreased sensation. 2. impaired skin integrity related to decreased peripheral circulation. 3. ineffective peripheral tissue perfusion related to decreased arterial blood flow. 4. activity intolerance related to imbalance between oxygen supply and demand.

b

A pouch-like bulge of an artery? A. Pseudoaneurysm B. Saccular Aneurysm C. Fusiform aneurysm

C (the presence of a bruit in the periumbilical area, although most abdominal aortic aneurysms, AAA, are asymptomatic, on physical exam a pulsatile mass in the periumbilical area slightly to the left of the midline may be detected, and bruits may be audible with a stethoscope placed over the aneurysm. Hoarseness and dysphagia may occur with aneurysms of the ascending aorta and the aortic arch. Severe back pain with flank ecchymosis is usually present on rupture of an AAA, and neurologic loss in the lower extremities may occur from the pressure of a thoracic aneurysm.)

A surgical repair is planned for a patient who has a 5-cm abdominal aortic aneurysm (AAA). On physical assessment of the patient, the nurse would expect to find... A) hoarseness and dysphagia B) sever back pain with flank ecchymosis C) the presence of a bruit in the periumbilical area D) weakness in the lower extremities progressing to paraplegia

d

A synthetic bifurcation graft is used in aneurysm repair when an AAA extends into the ________ arteries. A. saccular B. synthetic graft C. all D. iliac E. endovascular graft f. renal

d (CT scan, The most accurate test to determine the diameter of the aneurysm and whether a thrombus is present. The other tests may also be used, but the CT yields the most descriptive results.)

A thoracic aortic aneurysm is found when a patient has a routine chest radiograph. The nurse anticipates that additional diagnostic testing to determine the size and structure of the aneurysm will include... A) angiography B) Ultrasonography C) echocardiography D) CT scan

a (Phantom limb pain sensation is a real experience with no know cause or cure. The pain must be acknowledged and interventions to relieve the discomfort explored)

After an amputation of a limb, a client begins to experience extreme discomfort in the area where the limb once was. The nurse's greatest concern at this time is: A. Addressing the pain B. Reversing feelings of hopelessness C. Promoting mobility in the residual limb D. Acknowledge the grieving for the lost limb

b (Rationale: Patients should avoid temperature extremes by exercising indoors when it is cold. To avoid burn injuries, the patient should use warm, rather than hot, water to warm the hands. Pseudoephedrine is a vasoconstrictor and should be avoided. There is no reason to avoid taking aspirin and NSAIDs with Raynaud's phenomenon.)

After teaching a patient with newly diagnosed Raynaud's phenomenon about how to manage the condition, which behavior by the patient indicates that the teaching has been effective? A. The patient avoids the use of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). B. The patient exercises indoors during the winter months. C. The patient places the hands in hot water when they turn pale. D. The patient takes pseudoephedrine (Sudafed) for cold symptoms.

c (The initial nursing action should be to assess the patient's knowledge level and feelings about the options available. Discussion about the patient's option to not have the procedure, the seriousness of the condition, or rehabilitation after the procedure may be appropriate after the nurse knows more about the patient's current level of knowledge and emotional state.)

After the health care provider has recommended an amputation for a patient who has ischemic foot ulcers, the patient tells the nurse, "If they want to cut off my foot, they should just shoot me instead." Which response by the nurse is best? A. "Many people are able to function normally with a foot prosthesis." B. "I understand that you are upset, but you may lose the foot anyway." C. "Tell me what you know about what your options for treatment are." D. "If you do not want the surgery, you do not have to have an amputation."

b

During conventional aortic aneurysm repair, a ______ _______ is sutured to the aorta above and below the aneurysm, and the native aorta is replaced around the site. A. saccular B. synthetic graft C. all D. iliac E. endovascular graft f. renal

b (the cause of the aneurysm is a systemic vascular disease, because atherosclerosis is a systemic disease, the patient with an AAA is likely to have cardiac, pulmonary, cerebral, or lower-extremity vascular problems that should be noted and monitored throughout the perioperative period.)

During preop preparation of the patient scheduled for a AAA, the nurse establishes baseline data for the patient knowing that... A. All physiologic processes will be altered postop B. The cause of the aneurysm is a systemic vascular disease C. Surgery will be cancelled if any physiologic function is not normal D. BP and heart rate (HR) will be maintained well below the baseline levels during the postop peroid

d (The onset of aortic dissection involving the distal descending aorta is usually characterized by a sudden, severe, tearing pain in the back, and as it progresses down the aorta, the kidneys, abdominal organs, and lower extremities may begin to show evidence of ischemia. Aortic dissections of the ascending aorta and aortic arch may affect the heart and circulation to the head, with the development of murmurs, ventricular failure, and cerebral ischemia.)

During the nursing assessment of the patient with a distal descending aortic dissection, the nurse would expect the patient to manifest what? A. Cardiac murmur characteristic of aortic valve insufficiency B. Altered LOC with dizziness and weak carotid pulses C. Severe hypotension and orthopnea and dyspnea of pulmonary edema D. Severe "ripping" back or abdominal pain with decreasing urine output

b (the BP and all peripheral pulses are evaluated at least every hour in the acute postop period to ensure that BP is adequate and that extremities are being perfused. BP is kept within normal range. If it is too low, thrombosis of the graft may occur; if it is too high it may cause leaking or rupture at the suture line. Hypotheramis is induced during surgery, but the patient is rewarmed as soon as surgery is completed. Fluid replacement to maintain urine output at 100 mL/hr would increase the BP too much)

During the patient's acute post op period following repair of an aneurysm, the nurse should ensure that a) hypothermia is maintained to decrease oxygen need. b) the BP and all peripheral pulses are evaluated at least every hour. c) IV fluids are administered at a rate to maintain hourly urine output of 100 mL. d) the patient's BP is kept lower than baseline to prevent leaking at the suture line.

4 (Rationale: A decreased or absent pulse together with a cool, pale, mottled, or painful extremity may indicate embolization or graft occlusion.)

Following an aortic aneurysm repair, the patient suddenly develops severe pain in the right lower extremity. The right pedal pulse is decreased, and the right foot is cool and pale. The nurse suspects 1. hypothermia. 2. a wound infection. 3. bleeding from the graft site. 4. an embolization or graft occlusion.

a (A change in level of consciousness and ability to speak; because during a repair of an AAA, the blood supply to the carotid arteries may be interrupted, leading to neurologic complications manifested by a decreased LOC and altered pupil responses to light as well as changes in facial symmetry, speech, and movement of upper extremities. The thorax is opened is opened for ascending aortic surgery, and shallow breathing, poor cough, and decreasing chest drainage are expected. Often, lower limb pulses are normally decreased or absent for a short time following surgery.)

Following an ascending aortic aneurysm repair, which of the following findings should the nurse report immediately to the health care provider? a) a change in LOC and ability to speak b) shallow respirations and poor coughing c) decreased drainage from the chest tubes d) lower-extremity pulses that are decreased from preoperative baseline

d (I should take the pulses in my extremities and let the doctor know if they get too fast or too slow; patients are taught to palpate peripheral pulses to identify changes in their quality or strength, but the rate is not a significant factor in peripheral perfusion. The color and temperature of the extremities are also important for the patient to observe. The remaining statements are all true)

Following discharge teaching with a male patient with an AAA repair, the nurse determines that further instruction is needed when the patient says, a) I should avoid heavy lifting b) I may have some permanent sexual dysfunction as a result of the surgery c) I should maintain a low-fat and low-cholesterol diet to help keep the new graft open d) I should take the pulses in my extremities and let the doctor know if they get too fast or too slow.

a

Identify at least one observation made by the nurse that would indicate the presence of the following complications of aortic aneurysm repair. Graft thrombosis A. a decreased or absent pulses in conjunction with cool, painful extremities below the level of repair B. cardiac dysrhythmias, chest pain C. absent bowel sounds, abdominal distention, diarrhea, bloody stools D. increased temperature and WBC; surgical sit inflammation or drainage

c

Identify at least one observation made by the nurse that would indicate the presence of the following complications of aortic aneurysm repair. Bowel infarction A. a decreased or absent pulses in conjunction with cool, painful extremities below the level of repair B. cardiac dysrhythmias, chest pain C. absent bowel sounds, abdominal distention, diarrhea, bloody stools D. increased temperature and WBC; surgical sit inflammation or drainage

d

Identify at least one observation made by the nurse that would indicate the presence of the following complications of aortic aneurysm repair. Graft infection A. a decreased or absent pulses in conjunction with cool, painful extremities below the level of repair B. cardiac dysrhythmias, chest pain C. absent bowel sounds, abdominal distention, diarrhea, bloody stools D. increased temperature and WBC; surgical sit inflammation or drainage

b

Identify at least one observation made by the nurse that would indicate the presence of the following complications of aortic aneurysm repair. Myocardial ischemia A. a decreased or absent pulses in conjunction with cool, painful extremities below the level of repair B. cardiac dysrhythmias, chest pain C. absent bowel sounds, abdominal distention, diarrhea, bloody stools D. increased temperature and WBC; surgical sit inflammation or drainage

d (Many patients with aortic aneurysms also have peripheral arterial disease, so the nurse should check the preoperative assessment to determine whether pulses were present before surgery before notifying the health care providers about the absent pulses. Because the patient's symptoms may indicate graft occlusion or multiple emboli and a possible need to return to surgery, it is not appropriate to wait 30 minutes before taking action. Warm blankets will not improve the circulation to the patient's legs.)

Immediately after repair of an abdominal aortic aneurysm, a patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first? A. Wrap both the legs in warm blankets. B. Notify the surgeon and anesthesiologist. C. Document that the pulses are absent and recheck in 30 minutes. D. Review the preoperative assessment form for data about the pulses.

b (Rationale: Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. The other patient statements are correct and indicate that teaching has been successful)

In evaluating the patient outcomes following teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says, A. "I will have to buy some loose clothing that does not bind across my legs or waist." B. "I will use a heating pad on my feet at night to increase the circulation and warmth in my feet." C. "I will walk to the point of pain, rest, and walk again until I develop pain for a half hour daily." D. "I will change my position every hour and avoid long periods of sitting with my legs down."

d (Compression is essential for treating chronic venous insufficiency, CVI, healing venous ulcers, and preventing ulcer recurrence. Use of custom-fitted graduated compression stockings is one option for compression therapy.)

In planning patient care and teaching for the patient with venous leg ulcers, the nurse recognizes that the most important intervention in healing and control of this condition is: A. sclerotherapy B. taking horse chestnut extract daily C. using moist environment dressing D. applying graduated compression stockings

d

Major complications of aortic aneurysm repair are associated with involvement or obstruction of the _______ arteries. A. saccular B. synthetic graft C. all D. iliac E. endovascular graft F. renal

b (Phantom limb pain is treated like any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. The compression bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it still requires treatment now.)

On the first postoperative day, a patient with a below-the-knee amputation complains of pain in the amputated limb. Which action is best for the nurse to take? A. Explain the reasons for the phantom limb pain. B. Administer prescribed analgesics to relieve the pain. C. Loosen the compression bandage to decrease incisional pressure. D. Remind the patient that this phantom pain will diminish over time.

c

Repair of ______ aneurysms requires cross-clamping of the artery proximal and distal to the aneurysm. A. saccular B. synthetic graft C. all D. iliac E. endovascular graft f. renal

e

Repair of an aortic aneurysm by placing an aortic graft inside the aneurysm through the femoral artery is called the _______ _______. A. saccular B. synthetic graft C. all D. iliac E. endovascular graft F. renal

b (The decreasing urine output is evidence that either the patient needs volume or there is reduced renal blood flow. The physician will want to be notified as soon as possible of this change in condition and may order labs)

Priority Decision: patient who is postoperative following repair of an AAA has been receiving intravenous fluids at 125 mL/hr continuously for the last 12 hours. Urine output for the last 4 hours has been 60 mL, 42 mL, 28 mL, and 20 mL the last hour. The priority action that the nurse should take is to.. A. Monitor for a couple more hours B. Contact the physician and report the decrease in urine output C. Check that the infusion device is set at the correct rate and infusing correctly D. Send blood for electrolytes, blood urea nitrogen (BUN), and creatinine

c (Rationale: Postoperative priorities include administration of intravenous, IV, fluids and maintenance of renal perfusion. An adequate blood pressure is important to maintain graft patency, and administration of IV fluids and blood components, as indicated, is essential for adequate blood flow. The nurse should evaluate renal function by hourly urine output measurements and monitoring daily blood urea nitrogen, BUN, and serum creatinine levels. Irreversible renal failure may occur after aortic surgery, particularly in high-risk individuals.)

Priority nursing measures after an abdominal aortic aneurism repair include: A. assessment of cranial nerves and mental status B. administration of IV heparin and monitoring aPTT C. administration of IV fluids and monitoring of kidney function D. elevation of legs and application of graduated compression stockings

b

Two serious complications of PAD that frequently lead to lower limb amputation are ______________ and ___________. A. intermittent claudication B. non-healing ischemic ulcers and gangrene C. 0.77; mild D. rest

c (Rationale: Rest pain most often occurs in the forefoot or toes and is aggravated by limb elevation. Rest pain occurs when there is insufficient blood flow to meet basic metabolic requirements of the distal tissues. Rest pain occurs more often at night because cardiac output tends to drop during sleep and the limbs are at the level of the heart. Patients often try to achieve partial pain relief by dangling the leg over the side of the bed or sleeping in a chair to allow gravity to maximize blood flow.)

Rest pain is a manifestation of PAD that occurs due to a chronic: A. vasospasm of small cutaneous arteries in the feet B. increase in retrograde venous blood flow in the legs C. decrease in arterial blood flow to the nerves of the feet D. decrease in arterial blood flow to the leg muscles during exercise

d (Rationale: The pain and decreased urine output suggest a renal artery embolism, and monitoring of renal function is needed. The data are not consistent with the complications of infection, hypovolemia, or bleeding.)

Several hours after an open surgical repair of an abdominal aortic aneurysm, the patient develops a urinary output of 20 mL/hr for 2 hours. The nurse notifies the health care provider and anticipates orders for A. an additional antibiotic. B. a white blood cell (WBC) count. C. a decrease in IV infusion rate. D. a blood urea nitrogen (BUN) level.

a

The classic ischemic pain of PAD is known as _______ _________. A. intermittent claudication B. non-healing ischemic ulcers and gangrene C. 0.77; mild D. rest

a

The disruption of all layers of an artery with bleeding? A. Pseudoaneurysm B. Saccular Aneurysm C. Fusiform aneurysm

b (Rationale: The initial goals of therapy for acute aortic dissection without complications are blood pressure, BP, control and pain management. BP control reduces stress on the aortic wall by reducing systolic BP and myocardial contractility.)

The first priority of collaborative care of a patient with a suspected acute aortic dissection is to: A. reduce anxiety B. control blood pressure C. monitor for chest pain D. increase myocardial contractility

d (The purpose of elevating the feet is to enhance venous flow from the feet to the right atrium, which is best accomplished by placing two pillows under the feet and one under the thighs. Placing the patient in the Trendelenburg position will lower the head below heart level, which is not indicated for this patient. Placing pillows under the calf or elevating the bed at the knee may cause blood stasis at the calf level)

The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with deep vein thrombosis. The best method for the nurse to use in elevating the patient's feet is to A. place the patient in the Trendelenburg position. B. place two pillows under the calf of the affected leg. C. elevate the bed at the knee and put pillows under the feet. D. put one pillow under the thighs and two pillows under the lower legs.

a (IM injections are avoided in patients receiving anticoagulation. A PTT of 50 seconds is withinthe therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by VTE.)

The health care provider prescribes an infusion of argatroban (Acova) and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). The nurse will plan to A. avoid giving any IM medications to prevent localized bleeding. B. discontinue the infusion for PTT values greater than 50 seconds. C. monitor posterior tibial and dorsalis pedis pulses with the Doppler. D. have vitamin K available in case reversal of the argatroban is needed.

a (Relief of pain is an indication that the dissection has stabilized, and it may be treated conservatively for an extended time with drugs that lower BP and decrease myocardial contractility. Surgery is usually indicated for dissections of the ascending aorta or if complications occur)

The nurse evaluates that treatment for the patient with an uncomplicated aortic dissection is successful when.. A. Pain is relieved B. BP is within normal range C. Surgical repair is completed D. Renal output is maintained at 30 mL/hr

a (Patients taking Coumadin are taught to follow a consistent diet with regard to foods that are highin vitamin K, such as green, leafy vegetables. The other patient statements are accurate)

The nurse has initiated discharge teaching for a patient who is to be maintained on warfarin (Coumadin) following hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says, A. "I should reduce the amount of green, leafy vegetables that I eat." B. "I should wear a Medic Alert bracelet stating that I take Coumadin." C. "I will need to have blood tests routinely to monitor the effects of the Coumadin." D. "I will check with my health care provider before I begin or stop any medication."

c (Rationale: Enoxaparin is a low-molecular weight heparin that is administered for 10 to 14 days and prevents future clotting but does not dissolve existing clots. Fibrinolytic agents, e.g., tissue plasminogen activator or alteplase, will dissolve an existing clot. Enoxaparin is administered subcutaneously by injection.)

The nurse instructs a patient with a pulmonary embolism about enoxaparin (Lovenox). Which statement by the patient indicates understanding about the instructions? a. "The medicine will dissolve the clot in my lung." b. "I need to take this medicine with meals." c. "The medicine will be prescribed for 10 days." d. "I will inject this medicine into my abdomen."

c (Rationale: Warfarin is an anticoagulant that is used to prevent thrombi from forming on the walls of the atria during a fib. Once the medication is terminated, thrombi could again form. If one or more detach from the atrial wall, they could travel as cerebral emboli from the left atrium, or pulmonary emboli from the right atrium.)

The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed? A. Decreased cardiac output B. Increased blood pressure C. Cerebral or pulmonary emboli D. Excessive bleeding from incision or IV sites

d (Explanation of the underlying mechanism usually helps calm anxiety about a phantom pain experience)

When a client who had an above-the-knee amputation (AKA) complains of phantom limb sensations the nursing staff should: A. Reassure the client that theses sensations will pass B. Explain the psychological component involved to the client C. Encourage the client to get involved in diversional activities D. Describe the neurological mechanisms in language that the client understands

a (Rationale: The most common etiology of descending abdominal aortic aneurysm, AAA, is atherosclerosis. Risk factors include male gender, age 65 years or older, and tobacco use are the major risk factors for AAAs of atherosclerotic origin. Other risk factors include the presence of coronary or peripheral artery disease, high blood pressure, and high cholesterol.)

The nurse is teaching a patient about risk factors for aortic abdominal aneurysms. Which risk factors should the nurse include in the teaching plan? A. Smoking, high cholesterol, and hypertension B. Female gender, hyperhomocysteinemia, and substance abuse C. Diabetes mellitus, obesity, and metabolic syndrome D. Physical inactivity, African American, and renal insufficiency

c (Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease.)

The nurse performing an assessment with a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the left great toe would expect to find A. a positive Homans' sign. B. swollen, dry, scaly ankles. C. prolonged capillary refill in all the toes. D. a large amount of drainage from the ulcer.

1 (Rationale: Discharge instructions should include the following: Wash residual limb thoroughly each night with warm water and a bacteriostatic soap. Do not use any substance such as lotions, alcohol, powders, or oil on residual limb unless prescribed by the health care provider. To prevent flexion contractures, have patients avoid sitting in a chair for longer than 1 hour with hips flexed or having pillows under the surgical extremity.)

The nurse teaches a 58-year-old patient who had an above-the-knee amputation how to care for the residual limb. Which of the following statements by the patient indicates that teaching was effective? 1. "I should use only mild soap and water to clean the limb." 2. "I can apply lotion to the residual limb to keep the skin from cracking." 3. "Tincture of iodine or alcohol could be used to toughen the limb." 4. "I can elevate the residual limb on a pillow to prevent swelling when I am sitting or lying down."

d (Rationale: Patients with confirmed VTE should receive initial treatment with low-molecular-weight heparin, LMWH, unfractionated heparin, UFH, or fondaparinux and with warfarin for at least 5 days or until the international normalized ratio, INR, is >2.0 for 24 hours. Patients with multiple co-morbidities, complex medical issues, or a very large VTE usually are hospitalized for treatment and typically receive intravenous UFH. LMWH is recommended over UFH for most patients with acute VTE. Depending on the clinical presentation, patients often can be safely and effectively managed as outpatients.)

The recommended treatment for an initial VTE in an otherwise healthy person with no significant comorbidities would include: A. IV agratoban (Acova) as an inpatient B. IV unfractionated heparin as an inpatient C. subcutaneous unfractionated heparin as an outpatient D. subcutaneous low-molecular weight heparin as an outpatient

c

Uniform, circumferential dilation of artery? A. Pseudoaneurysm B. Saccular Aneurysm C. Fusiform aneurysm

a (Bleeding is a possible complication after catheterization of the femoral artery, so the nurse's first action should be to assess for changes in vital signs that might indicate hemorrhage. The other actions also are appropriate but can be done after determining that bleeding is not occurring.)

When caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty, which action should the nurse take first? A. Take the blood pressure and pulse rate. B. Check for the presence of pedal pulses. C. Assess the appearance of any ischemic ulcers. D. Start discharge teaching about antiplatelet drugs.

b (Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death. Circulation to the legs will decrease if the legs are elevated. Patients with PAD are taught to exercise to the point of feeling pain, rest, and then resume walking. Support hose are not used for patients with PAD.)

When developing a teaching plan for a patient newly diagnosed with peripheral artery disease (PAD), which information should the nurse include? A. "Exercise only if you do not experience any pain." B. "It is very important that you stop smoking cigarettes." C. "Try to keep your legs elevated whenever you are sitting." D. "Put on support hose early in the day before swelling occurs."

d (Feedback: All of the factors contribute to the patient's risk, but only the hypertension can potentially be modified to decrease the patient's risk for further expansion of the aneurysm.)

When discussing risk factor modification for a 60-year-old patient who has a 4-cm abdominal aortic aneurysm, the nurse will focus patient teaching on which of these patient risk factors? A. Male gender B. Marfan syndrome C. Abdominal trauma history D. Uncontrolled hypertension

d (Regardless of the location, atherosclerosis is responsible for peripheral arterial disease and is related to other cardiovascular disease and its risk factors.)

When obtaining a health history from a 72-year-old man with peripheral arterial disease(PAD) of the lower extremities, the nurse asks about a history of related conditions such as: a) Venous thrombosis b) Venous stasis ulcers c) Pulmonary embolism d) Carotid artery disease

3 (Rationale: Patients should be taught to exercise to the point of discomfort, stop and rest, and then resume walking until the discomfort recurs. Smoking cessation and proper foot care are also important interventions for patients with peripheral arterial disease.)

When teaching a patient with peripheral arterial disease, the nurse determines that further teaching is needed when the patient says, 1. "I should not use heating pads to warm my feet." 2. "I will examine my feet every day for any sores or red areas." 3. "I should cut back on my walks if they cause pain in my legs." 4. "I think I can quit smoking with the use of short-term nicotine replacement and support groups."

b (Loose, bloody stools at this time may indicate intestinal ischemia or infarction and should bereported immediately because the patient may need an emergency bowel resection. The otherfindings are normal on the first postoperative day after abdominal surgery.)

When the nurse is caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important to communicate to the health care provider? A. Absence of flatus B. Loose, bloody stools C. Hypotonic bowel sounds D. Abdominal pain with palpation

d ( The air bubble is not ejected before giving Arixtra. The other actions by the nurse areappropriate.)

Which action by a nurse who is administering fondaparinux (Arixtra) to a patient with venous thromboembolism (VTE) indicates that more education about the medication is needed? A. The nurse avoids rubbing the injection site after giving the medication. B. The nurse injects the medication into the abdominal subcutaneous tissue. C. The nurse fails to assess the partial thromboplastin time (PTT) before administration of the medication. D. The nurse ejects the air bubble in the syringe before administering the Arixtra.

b, d (Rationale: The patient with lower extremity venous thromboembolism, VTE, may or may not have unilateral leg edema, extremity pain, a sense of fullness in the thigh or calf, paresthesias, warm skin, erythema, or a systemic temperature >100.4F, 38 C. If the calf is involved, it may be tender to palpation. A positive Homans' sign, pain on forced dorsiflexion of the foot when the leg is raised, is a classic but very unreliable sign with frequent false positives.)

Which are probable clinical findings in a person with an acute VTE (select all that apply): A. pallor and coolness of the foot and calf B. mild to moderate calf pain and tenderness C. grossly diminished or absent pedal pulses D. unilateral edema and induration of the thigh E. palpable cord along a superficial varicose vein

b, c, d (Rationale: Both Buerger's disease and Raynaud's phenomenon have the following clinical manifestations in common: cold sensitivity, ischemic and gangrenous ulcers on fingertips, and color changes of the distal extremity, fingers or toes.)

Which clinical manifestation are seen in both patients with Buerger's disease and Raynaud's phenomenon (select all that apply): A. intermittent fevers B. sensitivity to cold temperatures C. gangrenous ulcers of fingertips D. color changes of fingers and toes E. episodes of superficial vein thrombosis

b (New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as oxygen administration and notification of the health care provider. The other findings are typical of VTE.)

Which information about a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? A. Complaint of left calf pain B. New onset shortness of breath C. Red skin color of left lower leg D. Temperature of 100.4° F (38° C)

d (Assisting a patient who has already been taught how to cough is part of routine postoperative care and within the education and scope of practice for an experienced NAP. Patient teaching and assessment of essential postoperative functions such as circulation and movement should be done by RNs)

Which nursing action in the care plan for a patient who had an open repair of an abdominal aortic aneurysm 3 days previously is appropriate for the nurse to delegate to experienced nursing assistive personnel (NAP)? A. Check the lower extremity strength and movement. B. Monitor the quality and presence of the pedal pulses. C. Teach the patient the signs of possible wound infection. D. Help the patient to use a pillow to splint while coughing.

b (Because renal artery occlusion can occur after endovascular repair, the nurse should monitorparameters of renal function such as intake and output. Chest tubes will not be needed forendovascular surgery, the recovery period will be short, and there will not be an abdominalwound.)

Which nursing action will be included in the plan of care after endovascular repair of an abdominal aortic aneurysm? A. Record hourly chest tube drainage. B. Monitor fluid intake and urine output. C. Check the abdominal wound for redness or swelling. D. Teach the reason for a prolonged rehabilitation process.

b (The patient's presentation is consistent with dissecting thoracic aneurysm, which will require rapid intervention. The other patients do not need urgent interventions.)

Which of these patients admitted to the emergency department should the nurse assess first? A. 62-year-old who has gangrenous ulcers on both feet B. 50-year-old who is complaining of "tearing" chest pain C. 45-year-old who is taking anticoagulants and has bloody stools D. 36-year-old who has right calf tenderness, redness, and swelling

a (The patient lies in the prone position several times daily to prevent flexion contractures of the hip. The limb sock should be changed daily. Lotion should not be used on the stump. The residual limb should not be elevated because this would encourage flexion contracture.)

Which statement by a patient who has had an above-the-knee amputation indicates that the nurse's discharge teaching has been effective? A. "I should lay on my abdomen for 30 minutes 3 or 4 times a day." B. "I should elevate my residual limb on a pillow 2 or 3 times a day." C. "I should change the limb sock when it becomes soiled or stretched out." D. "I should use lotion on the stump to prevent drying and cracking of the skin."

c (Compression of the leg is essential to healing of venous stasis ulcers. High dietary intake of protein, rather than carbohydrates, is needed. Prophylactic antibiotics are not routinely used forvenous ulcers. Moist environment dressings are used to hasten wound healing)

Which topic will the nurse include in patient teaching for a patient with a venous stasis ulcer on the right lower leg? A. Adequate carbohydrate intake B. Prophylactic antibiotic therapy C. Application of compression to the leg D. Methods of keeping the wound area dry

d (Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication. Finger pain associated with cold weather is typical of Raynaud's phenomenon.Fatigue that occurs sometimes with exercise is not typical of intermittent claudication, which is reproducible. Swelling associated with prolonged standing is typical of venous disease.)

While working in the outpatient clinic, the nurse notes that the medical record states that a patient has intermittent claudication. Which of these statements by the patient would be consistent with this information? A. "When I stand too long, my feet start to swell up." B. "Sometimes I get tired when I climb a lot of stairs." C. "My fingers hurt when I go outside in cold weather." D. "My legs cramp whenever I walk more than a block."