CH 26

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?

Stabilizing heart rate and blood pressure and easing anxiety

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?

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

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

1.5 to 2.5

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

3-5 days

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

50

Which assessment finding by the nurse is the most significant finding suggestive of aortic aneurysm?

Abdomen bruit

Which of the following medications is considered a thrombolytic

Alteplase

When teaching a client with peripheral vascular disease about foot care, a nurse should include which instruction?

Avoid wearing canvas shoes.

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

BP of 160/110 mm Hg

A health care provider wants a cross-sectional image of the abdomen to evaluate the degree of stenosis in a patient's left common iliac artery. The nurse knows to prepare the patient for which of the following?

Computed tomography angiography (CTA)

The nurse should always emphasize that the strongest risk factor for the development of atherosclerotic lesions is:

Cig smoking

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?

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

Which is a characteristic of arterial insufficiency?

Diminished or absent pulses

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?

Epinephrine

Which class of medication lyses and dissolves thrombi?

Fibrinolytic

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

Furosemide

Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of:

Hemorrhage.

A patient with diabetes is being treated for a wound on the lower extremity that has been present for 30 days. What option for treatment is available to increase diffusion of oxygen to the hypoxic wound?

Hyperbaric oxygen

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

Increased abdominal and back pain

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time?

Ineffective peripheral tissue perfusion related to venous congestion

Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity?

Intermittent claudication

A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities?

Participate in a regular walking program

Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued?

International normalized ratio (INR) is 2.5.

A nurse is completing an assessment on a client and discovers an enlarged, red, and tender lymph node. The nurse will describe and document the lymph node using which term?

Lymphadenitis

A client is diagnosed with peripheral arterial disease. Review of the client's chart shows an ankle-brachial index (ABI) on the right of 0.45. This indicates that the right foot has which of the following?

Moderate to severe arterial insufficiency

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

Pallor

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.

The nurse is assessing a client with severe hypertension. Which symptom indicates to the nurse that the client is experiencing dissection of the aorta?

Ripping sensation in the chest

The nurse is caring for a client with abdominal aortic aneurysm (AAA). Which assessment finding is most likely to indicate a dissection of the aneurysm?

Severe pain

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

Teach the client how to apply a graduated compression stocking.

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

Which of the following is the most common site for a dissecting aneurysm?

Thoracic area

The nurse is caring for a patient with venous insufficiency. For what should the nurse assess the patient's lower extremities?

Ulceration

The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is

contrast phlebography.

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should:

keep the affected leg level or slightly dependent.