CH 36

Which finding in the history of a client with an abdominal aortic aneurysm (AAA) is a risk factor for aneurysm formation? Peptic ulcer disease Deep vein thrombosis (DVT) Osteoarthritis Marfan syndrome

D. Marfan syndrome is a risk factor for cardiovascular disorders. Peptic ulcer disease is not a risk factor for AAA formation. AAA is an arterial problem; thus, DVT is not a related risk. Osteoarthritis is related to overuse of joints; it does not present a risk for AAA.

While caring for a client who has received recombinant tissue plasminogen activator (t-PA) for a large deep vein thrombus, the nurse becomes most concerned when the client develops which condition? Small amount of blood at the IV insertion site Heavy menstrual bleeding +1 pitting edema of the affected extremity Client stating that the year is 1967

D. The most serious complication from thrombolytic therapy is intracerebral bleeding, manifested by changes in the level of consciousness. Thrombolytics such as t-PA dissolve clots; even without this medication, a small amount of blood at the insertion site is not abnormal. Anticoagulants and thrombolytics may cause heavier-than-usual menstrual bleeding. Swelling is expected in the extremity with deep vein thrombosis.

A client with hypertension is started on verapamil (Calan). What teaching does the nurse provide for this client? "Consume foods high in potassium." "Monitor for irregular pulse." "Monitor for muscle cramping." "Avoid grapefruit juice."

D. Grapefruit juice should be avoided with verapamil because it can enhance the action of the drug. Foods high in potassium should be encouraged for clients taking diuretics, not calcium channel blockers such as verapamil. Bradycardia, not irregular pulse, is a typical side effect of verapamil. Muscle cramping may occur with statins, not with calcium channel blockers.

The nurse suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms? (Select all that apply.) Hypertension Tachycardia Bounding right pedal pulses Cold right foot Numbness and tingling of right foot Mottling of right foot and lower leg

D.E.F. Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion. Hypertension presents risk for atherosclerosis, but not for acute arterial occlusion. The pulse rate does not indicate occlusion, but rather quality. Absence of pulse, rather than bounding pulse, is a symptom of acute arterial occlusion.

A client has undergone an embolectomy for acute arterial occlusion after creation of a lower arm arteriovenous fistula for dialysis. Which finding does the nurse report to the provider immediately? Swelling and tenseness in the affected area Incisional pain and tenderness at the surgical site Pink, mobile fingers An order for heparin infusion

A. Compartment syndrome may develop after an embolectomy; swelling of skeletal muscle fibers causes increasing pain, swelling, and tenseness. A fasciotomy may be needed to preserve the limb. Incisional pain is expected. Pink fingers and mobility are normal physical assessment findings. Heparin may be prescribed to maintain patency of the vessel after clot removal.

Which are risk factors that are known to contribute to atherosclerosis-related diseases? (Select all that apply.) Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL Smoking Aspirin (acetylsalicylic acid [ASA]) consumption Type 2 diabetes Vegetarian diet

A.B.D. Having an LDL-C value of less than 100 mg/dL is optimal; 100 to 129 mg/dL is near or less than optimal; with LDL-C 130 to 159 mg/dL (borderline high), the client is advised to modify diet and exercise. Smoking is a modifiable risk factor and should be avoided or terminated, and diabetes is a risk factor for atherosclerotic disease. ASA is used as prophylaxis for atherosclerotic disease/coronary artery disease to prevent platelet adhesion. A diet high in whole grains, fruits, and vegetables is desirable to prevent atherosclerosis; vegetarians usually consume fruits, vegetables, and nonanimal sources of protein.

The nurse teaches a client who has had a myocardial infarction (MI) which information regarding diet? Less than 30% of the daily caloric intake should be derived from proteins. Use canola oil rather than palm oil. Consume 10 mg of fiber daily. Work toward lowering your high-density lipoprotein (HDL) cholesterol levels.

B. Palm oil is higher in saturated fats and should be avoided. Less than 30% of daily calories should come from fats. Clients should be encouraged to consume 30 g of dietary fiber daily. A higher HDL cholesterol level (good cholesterol) is more desirable; clients should strive to reduce low-density lipoprotein cholesterol (bad cholesterol) when elevated.

The nurse is caring for a client with dark-colored toe ulcers and blood pressure of 190/100 mm Hg. Which nursing action does the nurse delegate to the LPN/LVN? Assess leg ulcers for evidence of infection. Administer a clonidine patch for hypertension. Obtain a request from the health care provider for a dietary consult. Develop a plan for discharge, and assess home care needs.

B. Administering medication is within the scope of practice for the LPN/LVN. The RN is responsible for physical assessments, making referrals for other services, and developing the plan of care for the hospitalized client.

Which teaching point does the nurse include for a client with peripheral arterial disease (PAD)? "Elevate your legs above heart level to prevent swelling." "Inspect your legs daily for brownish discoloration around the ankles." "Walk to the point of leg pain, then rest, resuming when pain stops." "Apply a heating pad to the legs if they feel cold."

C. Exercise may improve arterial blood flow by building collateral circulation; instruct the client to walk until the point of claudication, stop and rest, and then walk a little farther. Elevating the legs in PAD decreases blood flow and increases ischemia. Brown discoloration around the ankles is characteristic of venous occlusive disease. Application of heat should be avoided in clients with PAD owing to lack of sensation and possible burns.

Which vascular assessment by the student nurse requires intervention by the supervising nurse? Measuring capillary refill in the fingertips Assessing pedal pulses by Doppler Measuring blood pressure in both arms Simultaneously palpating the bilateral carotids

D. Carotid arteries are palpated separately because of the risk for inadequate cerebral perfusion. Prolonged capillary filling generally indicates poor circulation; this is an appropriate assessment. Many clients with vascular disease have poor blood flow, and pulses that are not palpable may be heard with a Doppler probe. Because of the high incidence of hypertension in clients with atherosclerosis, blood pressure is assessed in both arms.

Which client who has just arrived in the emergency department does the nurse classify as emergent and needing immediate medical evaluation? A 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness A 64-year-old with chronic venous ulcers who has a temperature of 100.1° F (37.8° C) A 69-year-old with a 40-pack-year cigarette history who is reporting foot numbness A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic

D. The 70-year-old's history and clinical manifestations suggest possible aortic dissection. The nurse will immediately assess the client's blood pressure and plan for IV antihypertensive therapy, rapid diagnostic testing, and possible transfer to surgery. The 64-year-old is most stable and can be seen last. The 60-year-old and the 69-year-old should both be seen soon, but the 70-year-old client must be seen first.

The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the client's last appointment. Which actions by the client indicate that teaching has been effective? (Select all that apply.) Has maintained a low-sodium, no-added-salt diet Has lost 3 pounds since last seen in the clinic Cooks food in palm oil to save money Exercises once weekly Has cut down on caffeine

A.B.E. Clients with hypertension should consume low-sodium foods and should avoid adding salt. Weight loss can result in lower blood pressure. Caffeine promotes vasoconstriction, thereby elevating blood pressure. Although palm oil may be cost-saving, it is higher in saturated fat than canola, sunflower, olive, or safflower oil. The goal is to exercise three times weekly.

The nurse caring for a client who has had abdominal aortic aneurysm (AAA) repair would be most alarmed by which finding? Urine output of 20 mL over 2 hours Blood pressure of 106/58 mm Hg Absent bowel sounds +3 pedal pulses

A. Complications post AAA stent repair include bleeding, which may manifest as signs of hypovolemia and oliguria. Reduction of systolic blood pressure to 100 to 120 mm Hg is appropriate. Paralytic ileus may be a complication of AAA repair, but is not a priority over decreased urine output (think ABCs). +3 pedal pulses is a normal physical assessment finding.

A client has just undergone arterial revascularization. Which statement by the client indicates a need for further teaching related to postoperative care? "My leg might turn very white after the surgery." "I should be concerned if my foot turns blue." "I should report a fever or any drainage." "Warmness, redness, and swelling are expected."

A. Pallor is one of the signs of decreased perfusion along with increased pain, poikilothermia, paresthesia, pulselessness, and paralysis. The foot turning blue is a sign of poor perfusion. Fever or drainage would indicate an infection. Warmness, redness, and swelling indicate reperfusion, which is a good sign.

The nurse is assigned to all of these clients. Which client should be assessed first? The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago The client admitted with hypertensive crisis who has a nitroprusside (Nipride) drip and blood pressure of 149/80 mm Hg The client with peripheral vascular disease who has a left leg ulcer draining purulent yellow fluid The client who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot

A. The client who had PTA should have checks of vascular status and vital signs every 15 minutes in the first hour after the procedure. The client admitted with hypertensive crisis has stabilized and is not in need of immediate assessment. The client with peripheral vascular disease is the most stable and can be seen last. The client who had a right femoral-popliteal bypass is not in need of immediate assessment; he can be assessed after the PTA client is seen.

The nurse is caring for a client with peripheral arterial disease (PAD). For which symptoms does the nurse assess? Reproducible leg pain with exercise Unilateral swelling of affected leg Decreased pain when legs are elevated Pulse oximetry reading of 90%

A. Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances. Unilateral swelling is typical of venous problems such as deep vein thrombosis. With PAD, pain decreases with legs in the dependent position. Pulse oximetry readings reflect the amount of oxygen bound to hemoglobin; PAD results from atherosclerotic occlusion of peripheral arteries.

For a client with an 8-cm abdominal aortic aneurysm, which problem must be addressed immediately to prevent rupture? Heart rate 52 beats/min Blood pressure 192/102 mm Hg Report of constipation Anxiety

B. Elevated blood pressure can increase the rate of aneurysmal enlargement and risk for early rupture. The nurse must consider the client's usual pulse; however, bradycardia does not pose a risk for aneurysm rupture. Straining at stool can elevate blood pressure and pose a risk for dissection; however, a potential problem should not be addressed before an actual problem. Anxiety may be benign or may be a symptom of something serious; however, the elevated blood pressure is an immediate risk.

When administering furosemide (Lasix) to a client who does not like bananas or orange juice, the nurse recommends that the client try which intervention to maintain potassium levels? Increase red meat in the diet. Consume melons and baked potatoes. Add several portions of dairy products each day. Try replacing your usual breakfast with oatmeal or Cream of Wheat.

B. Melons and baked potatoes contain potassium. Red meat is high in saturated fat and is to be consumed sparingly. Dairy products are high in calcium. Cereals are fortified with iron; oatmeal contains fiber but not potassium.

When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? "I feel my heart beating in my abdominal area." "I just started to feel a tearing pain in my belly." "I have a headache. May I have some acetaminophen?" "I have had hoarseness for a few weeks."

B. Severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs, is indicative of impending rupture of AAA. The sensation of feeling the heartbeat in the abdomen is a symptom of AAA but not of dissection or rupture. Headache may be benign or indicative of cerebral aneurysm or increased intracranial pressure. Hoarseness, shortness of breath, and difficulty swallowing may be symptoms of thoracic aortic aneurysm.

A client is receiving unfractionated heparin (UFH) by infusion. Of which finding does the nurse notify the provider? Partial thromboplastin time (PTT) 60 seconds Platelets 32,000/mm3 White blood cells 11,000/mm3 Hemoglobin 12.2 g/dL

B. UFH can also decrease platelet counts. Notify the provider if the platelet count is below 100,000 to 120,000/mm3. Heparin-induced thrombocytopenia, an immune disorder, presents with platelets less than 150,000/mm3. A 60-second PTT reflects a therapeutic value within 1.5 to 2 times the normal value. Mild leukocytosis may be expected with deep vein thrombosis. A hemoglobin of 12.2 g/dL reflects a normal reading.

The nurse is teaching a client the precautions to take while on warfarin (Coumadin) therapy. Which statement made by the client demonstrates that teaching has been effective? "I can use an electric razor or a regular razor." "Eating foods like green beans won't interfere with my Coumadin therapy." "If I notice I am bleeding a lot, I should stop taking Coumadin right away." "When taking Coumadin, I may notice some blood in my urine."

B. Vitamin K is not found in foods such as green beans, so these foods will not interfere with the anticoagulant effects of Coumadin. Warfarin "thins" the blood; the risk for cutting oneself and bleeding is very high with the use of a regular razor, so the client should use an electric razor. Clients should apply pressure to bleeding wounds and should seek medical assistance immediately, but they should not discontinue warfarin therapy. Blood in the urine of a client taking warfarin therapy is not a side effect; the client should notify the health care provider immediately if this occurs.

A client's medical record shows these data: Physical Assessment crackles at bases right leg swelling right calf pain Findings Diagnostic Findings PTT 55 sec Positive, D-dimer hCG negative Provider Prescriptions Lovenox 40mg 2X daily Elevate right leg Doppler study right leg Which finding confirms the presence of a thromboembolism? Human chorionic gonadotropin (hCG) negative Crackles at bases Positive D-dimer ( >0.5mg/L) Right leg swelling

C. A D-dimer test is a global marker of coagulation activation; it measures fibrin degradation products produced from fibrinolysis (clot breakdown). The test is often used for the diagnosis of deep vein thrombosis when the client has few clinical signs, and stratifies clients into a high-risk category for reoccurrence. A negative hCG indicates that the client is not pregnant, removing risk for thromboembolism; this test does not confirm thromboembolism. Crackles may be present in a variety of conditions, including pneumonia, heart failure, and pulmonary embolism. Leg swelling may be related to injury and thromboembolism.

Which sign/symptom is essential for the nurse to report to the provider when caring for a client with Raynaud's phenomenon? Nifedipine (Procardia) administration caused the blood pressure to change from 134/76 to 110/68 mm Hg. The client's extremity became white, then red temporarily. The affected extremity becomes purple and cold. The client states that the digits are painful when they are white.

C. Cold, mottled extremities are indicative of occlusion, which could lead to gangrene. Vasodilating drugs are administered as treatment and may lower the blood pressure; this is not a significant drop. In severe cases, the attack lasts longer, and gangrene of the digits can occur. Pain, numbness, and cold are typical findings in Raynaud's phenomenon.

The nurse is caring for a client who is being treated for hypertensive emergency. Which medication prescribed for the client should the nurse question? Enalapril (Vasotec) Sodium nitroprusside (Nipride) Dopamine (Intropin) Clevidipine (Butyrate)

C. Dopamine is used for its inotropic and vasoconstrictive properties to raise blood pressure; it should not be used in hypertensive emergency. Enalapril, an angiotensin-converting enzyme inhibitor, may be used intravenously in hypertensive emergencies. Sodium nitroprusside, a direct-acting vasodilator, may be used intravenously to lower blood pressure quickly in hypertensive emergencies. Clevidipine, an intravenous calcium channel blocker, is used in hypertensive emergencies when oral therapy is not feasible.

The client undergoing femoral popliteal bypass states that he is fearful he will lose the limb in the near future. Which response by the nurse is most therapeutic? "Are you afraid you will not be able to work?" "If you control your diabetes, you can avoid amputation." "Your concerns are valid; we can review some steps to limit disease progression." "What about the situation concerns you most?"

C. It is important to validate the client's concern and offer needed information. Asking the client if he is afraid may identify fear but does not allow the client to discuss his specific concern. Controlling diabetes may help prevent amputation, but the nurse cannot state this with certainty. Asking the client about what concerns him the most is not as open-ended a question as the others; plus, the client has already stated his concern.

A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure? Ankle-brachial index Dye allergy Pedal pulses Gag reflex

C. Priority nursing care focuses on assessment for bleeding at the arterial puncture site and monitoring for distal pulses. Pulse checks must be assessed postprocedure to detect improvement (stronger pulses) or complications (diminished or absent pulses). Ankle-brachial index is a diagnostic study used to detect the presence of PAD; this is not necessary after PTA, which is an intervention to treat PAD. It is imperative to assess for dye allergy before performing PTA. Gag reflex is checked after procedures affecting the throat (e.g., endoscopy, bronchoscopy); the femoral artery is generally the access site for PTA.

Which symptom reported by a client who has had a total hip replacement requires emergency action? Localized swelling of one of the lower extremities Positive Homans' sign Shortness of breath and chest pain Tenderness and redness at the IV site

C. Shortness of breath and chest pain indicate a possible pulmonary embolism (PE), which can be life threatening. Orthopedic procedures create high risk for deep vein thrombosis (DVT) and PE. Although localized swelling is a symptom of DVT, it is not emergent. Pain in the calf on dorsiflexion of the foot (positive Homans' sign) appears in only a small percentage of clients with DVT, and false-positive findings are common; therefore, assessing for Homans' sign is not advised. Tenderness and redness at the IV site indicate phlebitis and are not emergent, but should be attended to after the emergency.

All of these client assignments have been made by the charge nurse. Which assignment is questionable? The RN with 3 years of experience caring for a client with a pulmonary embolism (PE) who is receiving heparin therapy The LPN/LVN with 5 years of experience caring for a client with leg ulcers who is awaiting nursing home placement The RN with 8 years of experience caring for a client with peripheral arterial disease (PAD) and a total cholesterol of 390 mg/dL The LPN/LVN with 20 years of experience caring for a client with a headache whose blood pressure is 210/150 mm Hg

D. The client with a headache and high blood pressure has unstable hypertension and is at risk for complications such as stroke, heart failure, or renal failure. The client should be assigned to an experienced RN, who can assess for end-organ damage and administer IV medications. (A better assignment would be to assign the client with a headache to an RN and the client with PAD to the LPN/LVN.) The RN with 3 years of experience has sufficient experience to provide care for a client with PE. The LPN/LVN can provide care for the client with leg ulcers, including dressing changes, if needed. The RN with 8 years of experience has sufficient knowledge to provide care for the client with PAD.

The nurse is teaching a young female client how to prevent venous thromboembolism specific to her hospital stay after intensive orthopedic surgery. Which statement made by the client indicates the need for further teaching? "I must stop taking my birth control pills." "I should drink lots of water so I don't get dehydrated." "I should exercise my legs when I have been sitting or standing for a long time." "If I wear pantyhose, I won't have to wear the stockings the hospital gives me."

D. Wearing the graduated compression stockings is a prevention specific to the hospital setting; they are designed to prevent blood clots, unlike regular pantyhose. Discontinuation of birth control pills is a routine prevention for thromboembolism, but this prevention is not specific to the client's acute hospitalization. Drinking a lot of water, where the quantity is not specified, may not be indicated for this client. Exercise is a prevention that can be done outside the hospital.

The professional nurse and the nursing student are caring for a group of clients with hypertension. Which problem identified by the nursing student correctly identifies the client at risk for secondary hypertension? Psychiatric disturbance High sodium intake Physical inactivity Kidney disease

D. Kidney disease is one of the most common causes of secondary hypertension. Psychiatric disturbance can exacerbate essential hypertension, but secondary hypertension is caused by a disease process or drugs. High sodium intake is a risk factor for essential hypertension, not for secondary hypertension, which is caused by disease states or medications. Physical inactivity is a risk factor for essential hypertension.