Cardio Review
Which finding would the nurse expect to identify when assessing the lower extremities of a client with varicose veins scheduled for sclerotherapy?
Ankle edema It results from venous pooling with increased hydrostatic pressure as fluid moves from intravascular to interstitial spaces.
Which information is essential for the nurse to include in the education plan for a client prescribed warfarin?
Periodic blood testing is necessary Testing is essential to determine dosing
Which clinical finding would the nurse expect when performing an assessment on a client with an abdominal aortic aneurysm?
Palpable pulsating abdominal mass. As the heart contracts, an expanding midline mass can be palpated to the left of the umbilicus.
Which finding from a client with a history of peripheral arterial disease (PAD) would the nurse discuss with the health care provider?
Paralysis, paleness, paresthesia, leg pain 9/10, and absent pedal pulse The nurse would contact the HCP if the five Ps are present in a client with PAD. These can indicate arterial occlusion and require immediate intervention.
Which statement explains why a client with intermittent claudication should quit smoking?
"Cigarette smoking is not suggested for clients who have vascular problems due to nicotine effects." It explains how nicotine is detrimental to physical status and promotes platelet aggregation and clot formation.
Which statement regarding prevention of thromboembolus in a client with varicose veins indicates the need for further teaching?
"I will massage my legs twice a day." Massaging is unsafe if a thrombus is present because it may dislodge and cause an embolus.
Which is the nurse's best response to a client considering sclerotherapy who asks the nurse to explain the cause of varicose veins?
"Incompetent valves of superficial veins" Incompetent valves result in retrograde venous flow and subsequent dilation of veins
Which response is most appropriate for a client asking about the causes of leg pain with intermittent claudication?
"Pain occurs in the legs while walking because there is a lack of oxygen to the muscles."
Which instruction will the nurse provide to a client prescribed home use of antiembolism stockings?
"Put the stockings on before rising in the morning." Support stockings apply external pressure on the veins, preventing the retrograde pressure or flow that may occur in the standing or sitting positions.
Which is the most beneficial lifestyle modification the nurse would teach a client diagnosed with peripheral arterial disease (PAD)?
"Stop smoking" In clients with PAD, the goal is to promote vasodilation and prevent vasoconstriction
Which assessment finding would the nurse expect in a client with peripheral arterial disease?
Absence of hair on the toes and reports of pain associated with exercising. The absence of hair on the toes occurs because of diminished circulation and pain is common because of increased need for oxygen.
Which is most important for the nurse to identify when determining why the lab INR results of a client receiving warfarin has been variable?
Adherence to the prescribed drug regimen.
Which intervention would the nurse implement for a client with peripheral arterial disease whose plan of care lists "skin breakdown caused by inadequate circulation" as a problem
Advise the client to not walk barefoot. Nursing interventions aimed at maintaing skin integrity inclue advising the client not to walk barefoot as this can cause injury to the feet.
Which is the priority nursing action after a femoral angiogram in a client with impaired peripheral pulses and signs of chronic hypoxia?
Assess the client's affected extremity Because of the trauma associated with insertion of the catheter during the procedure, the nurse would assess the involved extremity for sensation, motor ability, and arterial perfusion.
Which action would the nurse take to prevent excessive bruising when adminsitering subcutaneous heparin?
Avoid massaging the injection site after the injection. The site of injection would not be massaged to avoid dispersion of heparin around the site and subsequent bleeding into the area.
Which symptom is MOST LIKELY to be associated with thromboangiitis obliterans (Buerger disease) disorder?
Burning pain after exposure to cold. Thromboangiitis obliterans is characterized by vascular inflammation in the hands and feet, leading to thrombus formation.
A client with arterial insufficiency of both lower extremities is visited by the home health care nurse. An essential nursing intervention is to teach the client to do what? Which nursing intervention should the home health nurse teach to a client with bilateral lower extremity arterial insufficiency?
Check pulses in the legs regularly. Altered quantity and quality of pulses are the earliest indications of increasingly limited circulation.
Which is a common problem associated with Buerger disease?
Claudication in legs and feet. Claudication is a common symptom of Buerger disease.
Which physiologic effect of nicotine would the nurse explain to the group of clients with peripheral vascular disease?
Constriction of the peripheral vessels increases the pressure of the blood flow.
The nurse expects to hear which lung sounds in a client who is admitted with the diagnosis of mild chronic heart failure?
Crackles
Which classic sign is observed in peripheral vascular disease?
Pain, pallor, paresthesia Pain, pallor, paresthesia, pulselessness, and paralysis are the classic signs of peripheral vascular disease.
When assessing the client with peripheral arterial disease, the nurse anticipates the presence of which clinical manifestation?
Dependent rubor, ulcers on the toes, delayed capillary refill. Peripheral arterial disease affects arterial circulation and results in delayed and impaired circulation to the extremities.
Which function of leukocytes are involved in inflammation?
Destruction of bacteria and cellular debris and release of vasoactive amines during allergic reactions . Leukocytes are involved in inflammation.
Which significant risk factor for coronary heart disease carry greater risk for women than for men?
Diabetes mellitus and LDLs
A client is suspected of having thrombophlebitis of the left lower extremity. For which clinical finding would the nurse assess the client?
Edema of the left leg Swelling of the extremity is indicative of thrombophlebitis because inflammation of the vein impairs venous return.
Which action would the nurse take to best reduce edema of lower extremities.
Elevate the legs.
Which nursing action would be appropriate when a client with chronic arterial insufficiency of the legs refuses a prescribed dose of aspirin, stating, "My legs are not in pain"?
Explain the reason for the medication and encourage the client to take it. Aspirin is given to the client to prevent platelet aggregation and possible DVT.
The nurse is collecting data from a client with varicose veins who is scheduled to have sclerotherapy. Which symptoms would the nurse expect the client to report?
Feeling of heaviness in both legs. Sclerotherapy is performed to improve impaired venous return which causes increased pressure, with symptoms of fatigue and heaviness.
Which conclusion would the nurse make about what is taking place in a client with an abdominal aortic aneurysm being prepared for surgery who complains of feeling lightheaded and is pale with a rapid pulse.
Going into shock. Shock ensues rapidly after a ruptured aortic aneurysm because of profound hemorrhage.
Which would the nurse identify as the primary cause of the pain experienced by a client with a coronary occlusion?
Heart muscle ischemia Ischemia causes tissue injury and the release of chemicals, such as bradykinin, that stimulate sensory nerves and produce pain.
Which stratergy to warm affected areas during a vasoconstrictive episode in a client with Raynaud disaese would the nurse find concerning?
Immersion in hot water. In Raynaud disaese, sensation is diminished during a vasoconstriction episode.
Which explanation will the nurse provide as the rationale for increased risk of thrombosis to a client with polycythemia vera?
Increased blood thickness Polycythemia vera results in pathologically high concentrations of erythrocytes in the blood; increased viscosity promotes thrombus formation.
Which condition does the nurse consider as the most likely cause of the client's report that their legs hurt after walking for a short time, and the pain goes away with rest but returns when walking is resumed?
Intermittent claudication It is a classic symptom of peripheral arterial occlusive disease, and it is pain caused by too little blood flow and develops during exercise.
The nurse knows that in a client with peripheral artery disease, walking that sometimes results in severe pain in the calf muscles is best documented using which medical term?
Intermittent claudication It is pain that tresults when the arterial system is unable to provide adequate blood flow to the tissues in presence of increased demands for oxygen and nutrients during exercise; it is relieved by rest
A client with bilateral varicose veins of the lower extremities questions the nurse about the brownish discoloration of the lower legs. Which is the best explanation by the nurse, regarding the cause of this discoloration?
Leakage of red blood cells through the vascular wall. Increased venous pressure alters the permeability of the veins, allowing extravasation of RBC
The healthcare provider prescribes diagnostic testing for a client with abdominal pain who has a history of bradycardia with permanent pacemaker insertion, hypertension, and peripheral vascular disease. Which diagnostic test would lead the nurse to contact the HCP for clarification?
Magnetic resonance imagery (MRI) The client has a permanent pacemaker which should not be exposed to MRI because of the magnet. An obstructive series, KUB, and CT are not contraindicated.
Which action should the nurse choose to implement if thrombophlebitis is suspected in a postoperative client complaining of calf pain?
Maintain bed rest and notify the primary HCP. When thrombophlebitis is suspected, the client should be confined to the bed so that a thrombus is not dislodged, causing PE.
The nurse identifies that the afternoon international normalized ratio (INR) is 4.6 for a client who is on warfarin sodium after a total knee replacement several days ago. Which is the next action the nurse would take?
Maintain the client on bed rest until the HCP reviews the laboratory reults. An INR of 4.6 is higher than the desired therapeutic level of 2 to 3.5. It is prudent to maintain bed rest to prevent injury.
Which aciton would the nurse take if a client who had abdominal surgery 24 hours ago reports pain in the calf and the nurse's assessment reveals redness and swelling of the same calf?
Notify HCP They can indicate possible thrombophlebitis.
Which aciton would the nurse take when a client begins to manifest signs and symptoms associated with embolization?
Notify the primary HCP immediately.
Which clinical manifestation would the nurse expect in a client with varicose veins?
Presence of ankle edema, Increased muscle fatigue, and report of nocturnal leg cramps. Ankle edema, muscle fatigue, and nocturnal leg cramps are signs of varicose veins caused by venous dilation resulting from incompetent valves that are expected to prevent backflow.
Why would the nurse encourage active leg activities and foot exercise every 2 hours to the unaffected leg of a client with an open reduction and internal fixation of the hip?
Prevent clot formation. Active ROM exercises increase venous return in the unaffected leg, preventing complications of immobility, including thrombophlebitis.
A client is prescribed prolonged bed rest after surgery. Which complication would the nurse expect to prevent by teaching this client to avoid pressure on the popliteal space?
Pulmonary embolism
Which clinical finding would the nurse expect when completing the admission assessment on a client admitted with an abdominal aoritc aneurysm and surgery scheduled in the morning?
Pulsating abdominal mass.
Which would the nurse include in the client's teaching plan related to how to prevent thrombophlebitis?
Put on elastic stockings before arising. Donning elastic stockings before getting out of bed provides support and promotes venous return.
Which is a clinical sign of thrombophlebitis?
Redness and warmth of the calves Redness and warmth are clinical signs of thrombophlebitis.
Which acid-base imbalance causes the kidneys to increase excretion of bicarbonate in order to lower pH levels?
Respiratory alkalosis In respiratory alkalosis, the kidneys. excrete increased amounts of bicarbonate to lower pH levels.
Which intervention would the nurse expect to prevent the most common postsurgical complication after an open reduction and internal fixation of a fractured hip?
Sequential compression stockings Compressed air inflates the padded plastic stockings systematically from ankle to calf to thigh and then deflates. This promotes venous return and prevents venous stasis and thromboembolism.
Which clinical manifestation of hypothermia does the nurse expect to find in a person after prolonged exposure to cold weather?
Stupor and Paresthesia in affected body parts Stupor may occur because of slower cerebral metabolic processes. Peripheral vasoconstriction and effect of cold results in paresthesia in affected body parts.
In which position will the nurse place a client after surgery to remove varicose veins?
Supine with the legs elevated at a 15 degree angle Legs would be elevated to promote venous return by gravity.
Which would the nurse teach the client with varicose veins about knee length elastic stockings?
The stockings are to be applied before getting out of bed
Which explanation would the nurse teach to the client preoperatively regarding the use of pneumatic compression devices?
They help the venous blood return to the heart. DVT is a potential complication of any surgery lasting longer than 30 minutes.
When supporting vasodilation by the use of warmth for a client with peripheral arterial insufficiency, which action does the nurse caution the client to avoid?
Using a heating pad to warm the extremities. The client's extremities are less sensitive to thermal stress because of peripheral vascular problems, and burnsmay occur.
Which lifestyle modification would the nurse recommend for a client with peripheral arterial disease of the legs?
Walk more throughout the day. Maintain a slightly dependent position when resting. Use a thick moisturizer on your feet, and inspect them daily. Wear socks or insulated shoes at all times, even around the house. Eat a low fat and low cholesterol diet with a moderate amount of protein and carbohydrate.
The nurse would assess the client with a ruptured spleen for which early sign of decreased arterial pressure?
Weak radial pulses
Which client response would the nurse expect from a client with bilateral varicose veins?
Worsening ankle edema as the day progresses. When the legs are dependent, gravity and incompetent valves promote increased hydrostatic pressure in leg veins
