Prep U Chapter 30

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

1.5 to 2.5 times the baseline control.

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

50

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

BP of 160/110 mm Hg

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

Claudication

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

Hemorrhage.

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

Thoracic area

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 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." "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."

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

The nurse is caring for a patient who has started anticoagulant therapy with warfarin (Coumadin). When does the nurse understand that therapeutic benefits will begin? Within the first 24 hours Within 12 hours In 2 days In 3 to 5 days

In 3 to 5 days

What should the nurse do to manage persistent swelling in a client with severe lymphangitis and lymphadenitis? Inform the physician if the client's temperature remains low. Avoid elevating the area. 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? 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 an elastic sleeve Avoid elevating the area

Teach the client how to apply an elastic sleeve

A community health nurse teaches a group of older adults about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which statement? "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." "Because my family is from Italy, I have a higher risk of developing peripheral arterial disease." "The older I get the higher my risk for peripheral arterial disease gets." "I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels."

"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."

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

Alteplase

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: Urokinase. Reteplase. Streptokinase Alteplase.

Alteplase.

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. Check for the presence of tortuous veins bilaterally on the legs. Ask about any changes in skin color that occur in response to cold. Assess for unilateral swelling and tenderness of either leg.

Attempt to palpate the dorsalis pedis and posterior tibial pulses.

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

Dissecting

A patient is having an angiography to detect the presence of an aneurysm. After the contrast is administered by the interventionist, the patient begins to complain of nausea and difficulty breathing. What medication is a priority to administer at this time? Hydrocortisone (Solu-Cortef) Cimetidine (Tagamet) Epinephrine Metoprolol (Lopressor)

Epinephrine

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? Ineffective peripheral tissue perfusion related to venous congestion Excess fluid volume related to peripheral vascular disease Risk for injury related to edema Impaired gas exchange related to increased blood flow

Ineffective peripheral tissue perfusion related to venous congestion

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

Numbness, cool skin temperature, and pallor

A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures? "I walk only to the mailbox in my bare feet." "I have my wife look at the soles of my feet each day." "I like to soak my feet in the hot tub every day." "I stopped smoking and use only chewing tobacco."

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

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? Venous insufficiency Trauma Arterial insufficiency Neither venous nor arterial

Arterial insufficiency

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? Extend the leg, plantar flex the foot, and check for the patency of the dorsalis pedis pulse. Lower the patient's legs and massage the calf muscles to note any areas of tenderness. Elevate the patient's legs for 20 minutes and then lower them slowly while checking for areas of inadequate blood return. Dorsiflex the foot while the leg is elevated to check for calf pain.

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

he nurse is educating a patient with chronic venous insufficiency about prevention of complications related to the disorder. What should the nurse include in the information given to the patient? (Select all that apply.) Elevate the legs above the heart level for 30 minutes every 2 hours. Sit as much as possible to rest the valves in the legs. Avoid constricting garments. Sleep with the foot of the bed elevated about 6 inches. Sit on the side of the bed and dangle the feet.

Elevate the legs above the heart level for 30 minutes every 2 hours. Avoid constricting garments. Sleep with the foot of the bed elevated about 6 inches.

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 No arterial insufficiency Moderate to severe arterial insufficiency

Moderate to severe arterial insufficiency

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

Myocardial infarction (MI)

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

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

Recent pelvic surgery

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 A history of diabetes mellitus An active daily walking program History of increased aspirin use

Recent pelvic surgery

On a routine visit to the physician, a client with chronic arterial occlusive disease reports that he's stopped smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, which additional measure should the nurse recommend? Taking daily walks Abstaining from foods that increase levels of high-density lipoproteins (HDLs) Reducing daily fat intake to less than 45% of total calories Engaging in anaerobic exercise

Taking daily walks

The nurse is caring for a client who is scheduled to have a vein ligation in the morning. How would you describe a vein ligation to the client? Removal of the small saphenous vein. Removal of the great saphenous vein. Veins are tied off and removed. Veins are tied off and left in the leg.

Veins are tied off and left in the leg.

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. loss of hair on the lower portion of the left leg. a decrease in the left pedal pulse. pallor and coolness of the left foot.

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

The nurse teaches the client with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes depression of the cough reflex. diuresis. vasospasm. slowed heart rate.

vasospasm.

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

Risk factor modification

A nurse is admitting a new client with a deep vein thrombosis in her left leg. During the admission process, which information provided by the client would be a contraindication to anticoagulant therapy? Three vaginal births, the most recent 18 months ago Scheduled eye surgery in 1 week Diet that includes many green, leafy vegetables every day A cerebral vascular bleed 10 years ago

Scheduled eye surgery in 1 week

You are presenting a workshop at the senior citizens center about how the changes of aging predisposes clients to vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in the older adult? Aneurysm Coronary thrombosis Atherosclerosis Raynaud's disease

Atherosclerosis

The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack? Avoid situations that contribute to ischemic episodes. Report changes in the usual pattern of chest pain. Avoid fatty foods and exercise. Take over-the-counter decongestants.

Avoid situations that contribute to ischemic episodes

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? Urine output of 150 ml/hour and heart rate of 45 beats/minute Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute Urine output of 15 ml/hour and 2+ hematuria Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute

Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute

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

Border of the ulcer is irregular

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

Common iliac artery.

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 Constant, intense headache and falling blood pressure Constant, intense back pain and falling blood pressure Slow heart rate and high 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? Aching, cramping pain Superficial ulcer Diminished or absent pulses Pulses that are present but difficult to palpate

Diminished or absent pulses

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

Diminished or absent pulses

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

Increased abdominal and back pain

A client with Raynaud's disease complains of cold and numbness in the fingers. Which of the following would the nurse identify as an early sign of vasoconstriction? Gangrene Clubbing of the fingers Cyanosis Pallor

Pallor

A nurse is caring for a client following an arterial vascular bypass graft in the leg. What should the nurse plan to assess over the next 24 hours? Ankle-arm indices every 12 hours Color of the leg every 4 hours Peripheral pulses every 15 minutes after surgery Blood pressure every 2 hours

Peripheral pulses every 15 minutes after surgery

A patient complains of a "stabbing pain and a burning sensation" in his left foot. The nurse notices that the foot is a lighter color than the rest of the skin. The artery that the nurse suspects is occluded would be the: Posterior tibial. Popliteal. Common femoral. Internal iliac.

Posterior tibial.

While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first? Start an I.V. infusion of dextrose 5% in water (D5W). Monitor the partial thromboplastin time (PTT). Prepare to administer protamine sulfate. Decrease the heparin infusion rate.

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

Protamine sulfate

A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions? Increasing blood pressure and reducing mobility Decreasing blood pressure and increasing mobility Increasing blood pressure and monitoring fluid intake and output Stabilizing heart rate and blood pressure and easing anxiety

Stabilizing heart rate and blood pressure and easing anxiety

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 antiembolytic 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.

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? "Enoxaparin will dissolve the clot, and warfarin will prevent any more clots from occurring." "The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect." "Because of the potential for a pulmonary embolism, it is important for you to take at least two anticoagulants." "Administration of two anticoagulants decreases the risk of recurrent venous thrombosis."

"The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect."

Which is a risk factor for venous disorders of the lower extremities? Obesity Pacing wires Surgery Trauma

Obesity

A client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of thromboembolism? Romberg's Homans' Phalen's Rinne

Homans'

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

Fibrinolytic

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." "If you feel any discomfort, stop and we will use a wheelchair to take you back to your room." "As soon as you feel pain, we will go back and elevate your legs." "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."

Heparin therapy is usually considered therapeutic when the activated partial thromboplastin time (aPTT) is how many times higher than a normal value? 1 to 1.5 1.5 to 2 2 to 2.5 2.5 to 3

2 to 2.5

The nurse is monitoring a patient who is on heparin anticoagulant therapy. What should the nurse determine the therapeutic range of the international normalized ratio (INR) should be? 2.0-3.0 4.0-5.0 7.0-8.0 5.0-6.0

2.0-3.0

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

Anterior surface of the foot near the ankle joint.

You are assessing a client recently admitted to your unit for hypotension. While assessing this client, you find a pulsatile mass near the umbilicus. What would you suspect? Coronary artery disease Aortic aneurysm Raynaud's disease Peripheral artery disease

Aortic aneurysm

A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless temporary change? Redness of the upper part of the feet Purplish stools Bluish urine Coldness of the soles

Bluish urine

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

Border regular and well demarcated

A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued? Prothrombin time (PT) is 0.5 times normal. Activated partial thromboplastin time (aPPT) is half of the control value International normalized ratio (INR) is 2.5. K+ level is 3.5.

International normalized ratio (INR) is 2.5.

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

Lowering the limb so that it is dependent.

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? Hematemesis Hypertensive crisis Rectal bleeding Severe back pain

Severe back pain

A client with venous insufficiency develops varicose veins in both legs. Which statement about varicose veins is accurate? The severity of discomfort isn't related to the size of varicosities. Sclerotherapy is used to cure varicose veins. Varicose veins are more common in men than in women. Primary varicose veins are caused by deep vein thrombosis (DVT) and inflammation.

The severity of discomfort isn't related to the size of varicosities.

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

The sympathetic nervous system.

The nurse is caring for a patient with venous insufficiency. What should the nurse assess the patient's lower extremities for? Rudor Dermatitis Ulceration Cellulitis

Ulceration

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

Ulcers and infection in the edematous 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 gater 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? Arterial insufficiency Venous insufficiency Trauma Neither venous nor arterial insufficiency

Venous insufficiency

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

abdominal aorta, just below the renal arteries.

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. contrast phlebography. air plethysmography.

contrast phlebography.

The most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program is that this form of exercise: decreases venous congestion. increases high-density lipoprotein (HDL) level. aids in weight reduction. reduces stress.

decreases venous congestion.

To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a 45-degree angle and then have the client sit up. The nurse suspects arterial insufficiency if the assessment reveals: a 30-second filling time for the veins. dependent pallor. no rubor for 10 seconds after the maneuver. elevational rubor.

dependent pallor.

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: encouraging ambulation to prevent pooling of blood. elevating the extremity to prevent pooling of blood. forcing blood into the deep venous system. providing warmth to the extremity.

forcing blood into the deep venous system.

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should: place a heating pad around the affected calf. elevate the affected leg as high as possible. shave the affected leg in anticipation of surgery. keep the affected leg level or slightly dependent.

keep the affected leg level or slightly dependent

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

Demonstrate how to apply and remove elastic support stockings.

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

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

A nurse and physician are preparing to visit a hospitalized client with perepheral 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 can walk about 50 feet before getting pain in the right lower leg. The client's fingers tingle when left in one position for too long. The client's legs awaken him during the night with itching.

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

Vasodilation or vasoconstriction produced by an external cause will interfere with a nurse's accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should: keep the client uncovered. match the room temperature to the client's body temperature. keep the client warm. maintain room temperature at 78° F (25.6° C).

keep the client warm.