Chapter 30: Assessment and Management of Patients with Vascular Disorders and Problems of Peripheral Circulation NCLEX
B ("Shoes made of synthetic material are best for my feet." Correct Explanation: pg835 The client should wear leather shoes with an extra-depth toebox. Synthetic shoes do not allow air to circulate.)
A nurse is providing education about maintaining tissue integrity to a client with peripheral arterial disease. Which of the following statements by the client indicates a need for clarification? a) "I can use lamb's wool between my toes if necessary." b) "Shoes made of synthetic material are best for my feet." c) "I should apply powder daily because my feet perspire." d) "It is important to apply sunscreen to the top of my feet when wearing sandals."
A, B, C, D, E (• Hematoma • Embolization • Dissection of the vessel • Bleeding • Stent migration Explanation: Page 830 Complications from PTA include hematoma, embolization dissection of the vessel, bleeding, intimal damage (dissection), and stent migration.)
Choice Multiple question - Select all answer choices that apply. Which of the following are complications of percutaneous transluminal balloon angioplasty (PTA)? Select all that apply. a) Embolization b) Bleeding c) Dissection of the vessel d) Hematoma e) Stent migration
B (Claudication Explanation: Page 837 Trental and Pletal are the only medications specifically indicated for the treatment of claudication. Thromboemboli, hypertension, and elevated triglycerides are not indications of Trental.)
Pentoxifylline (Trental) is a medication used for which of the following? a) Elevated triglycerides b) Claudication c) Thromboemboli d) Hypertension
c (In 3 to 5 days Oral anticoagulants, such as warfarin, are monitored by the PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0) (Holbrook et al., 2012).)
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? a) Within 12 hours b) Within the first 24 hours c) In 3 to 5 days d) In 2 days
A (The client can walk about 50 feet before getting pain in the right lower leg. Correct Explanation: pp. 823-824 Intermittent claudication is caused by the inability of the arterial system to provide adequate blood flow to the tissues when increased demands are made for oxygen and nutrients during exercise. Pain is then experienced. When the client rests and decreases demands, the pain subsides. The client can then walk the same distance and repeat the process.)
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? a) The client can walk about 50 feet before getting pain in the right lower leg. b) The client experiences shortness of breath after walking about 50 feet. c) The client's fingers tingle when left in one position for too long. d) The client's legs awaken him during the night with itching.
B (Peripheral pulses every 15 minutes following surgery.)
A nurse is caring for a client following an arterial vascular bypass graft in the leg. Over the next 24 hours, what should the nurse plan to assess? a) Color of the leg every 4 hours b) Peripheral pulses every 15 minutes following surgery c) Blood pressure every 2 hours d) Ankle-arm indices every 12 hours
d ("Shoes made of synthetic material are best for my feet." The client should wear leather shoes with an extra-depth toebox. Synthetic shoes do not allow air to circulate.)
A nurse is providing education about maintaining tissue integrity to a client with peripheral arterial disease. Which of the following statements by the client indicates a need for clarification? a) "It is important to apply sunscreen to the top of my feet when wearing sandals." b) "I can use lamb's wool between my toes if necessary." c) "I should apply powder daily because my feet perspire." d) "Shoes made of synthetic material are best for my feet."
d (Myocardial infarction (MI) Aortic dissection may be mistaken for an acute MI, which could confuse the clinical picture and initial treatment. Aortic dissection is not mistaken for stroke, pneumothorax, or angina.)
Aortic dissection may be mistaken for which of the following disease processes? a) Stroke b) Angina c) Pneumothorax d) Myocardial infarction (MI)
B, C, D, E (• Impairs transport and cellular use of oxygen • Reduces circulation to the extremities • Increases blood viscosity • Causes vasospasm Correct Explanation: Page 828 Nicotine from tobacco products causes vasospasm and can dramatically reduce circulation to the extremities. Tobacco smoke also impairs transport and cellular use of oxygen and increases blood viscosity.)
Choice Multiple question - Select all answer choices that apply. Which of the following is accurate regarding the effects of nicotine and tobacco smoke on the body? Select all that apply. a) Decreases blood viscosity b) Causes vasospasm c) Impairs transport and cellular use of oxygen d) Reduces circulation to the extremities e) Increases blood viscosity
B (50 Correct Explanation: Page 837 The distal outflow vessel must be at least 50% patent for the graft to remain patent.)
In a patient with a bypass graft, the distal outflow vessel must be at least what percentage patent for the graft to remain patent? a) 30 b) 50 c) 40 d) 20
d (abdominal aorta, just below the renal arteries. About 75% of aneurysms occur in the abdominal aorta, just below the renal arteries (Debakey type I aneurysms). Debakey type II aneurysms occur in the aortic arch around the ascending and descending aorta, whereas Debakey type III aneurysms occur in the descending aorta, beyond the subclavian arteries.)
The most common site of aneurysm formation is in the: a) aortic arch, around the ascending and descending aorta. b) descending aorta, beyond the subclavian arteries. c) ascending aorta, around the aortic arch. d) abdominal aorta, just below the renal arteries.
B (Vasospasm Correct Explanation: Page 831 Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities. Tobacco smoke also impairs transport and cellular use of oxygen and increases blood viscosity. Patients with arterial insufficiency who smoke or chew tobacco must be fully informed of the effects of nicotine on circulation and be encouraged to stop.)
The nurse teaches the patient with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes which of the following? a) Diuresis b) Vasospasm c) Slowed heart rate d) Depression of the cough reflex
c (dependent pallor. If arterial insufficiency is present, elevation of the limb would yield a pallor from the lack of circulation. Rubor and increased venous filling time would suggest venous problems secondary to venous trapping and incompetent valves.)
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) a 30-second filling time for the veins. b) no rubor for 10 seconds after the maneuver. c) dependent pallor. d) elevational rubor.
a (Increased abdominal and back pain Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be affected.)
Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending? a) Increased abdominal and back pain b) Elevated blood pressure and rapid respirations c) Decreased pulse rate and blood pressure d) Retrosternal back pain radiating to the left arm
a (left calf circumference 1" (2.5 cm) larger than the right. Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased pulse, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT.)
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: a) left calf circumference 1" (2.5 cm) larger than the right. b) a decrease in the left pedal pulse. c) loss of hair on the lower portion of the left leg. d) pallor and coolness of the left foot.
d (keep the client warm. The nurse should keep the client covered and expose only the portion of the client's body that she's assessing. The nurse should also keep the client warm by maintaining his room temperature between 68° F and 74° F (20° and 23.3° C). Extreme temperatures aren't good for clients with PVD. The valves in their arteries and veins are already insufficient, and exposing them to vast changes in temperature could affect assessment findings. Keeping the client uncovered would cause him to become chilled. Matching the room temperature to the client's body temperature is inappropriate.)
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: a) match the room temperature to the client's body temperature. b) maintain room temperature at 78° F (25.6° C). c) keep the client uncovered. d) keep the client warm.
b (Prepare to administer protamine sulfate. Frank hematuria indicates excessive anticoagulation and bleeding — and heparin overdose. The nurse should discontinue the heparin infusion immediately and prepare to administer protamine sulfate, the antidote for heparin. Decreasing the heparin infusion rate wouldn't prevent further bleeding. Although the nurse should continue to monitor PTT, this action should occur later. An I.V. infusion of D5W may be administered, but only after protamine has been given.)
While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first? a) Monitor the partial thromboplastin time (PTT). b) Prepare to administer protamine sulfate. c) Decrease the heparin infusion rate. d) Start an I.V. infusion of dextrose 5% in water (D5W).
c (Anastomotic An anastomotic aneurysm occurs as a result of infection at arterial suture or graft sites. Dissection results from a rupture in the intimal layer, resulting in bleeding between the intimal and medial layers of the arterial wall. Saccular aneurysms collect blood in the weakened outpouching. In a false aneurysm, the mass is actually a pulsating hematoma.)
A nurse is changing a dressing on an arterial suture site. The site is red, with foul-smelling drainage. Based on these symptoms, the nurse is aware to monitor for which type of aneurysm? a) Saccular b) False c) Anastomotic d) Dissecting
A (Ineffective peripheral tissue perfusion Correct Explanation: Page 832 The goal is to increase arterial blood supply to the extremities; the priority nursing diagnosis is Ineffective peripheral tissue perfusion related to compromised circulation.)
A nurse is developing a nursing care plan for a client with peripheral arterial disease. Which of the following will be the priority nursing diagnosis? a) Ineffective peripheral tissue perfusion b) Impaired tissue integrity c) Ineffective self-health management d) Ineffective thermoregulation
B (Peripheral pulses every 15 minutes following surgery Correct Explanation: p. 838 The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the patient's status remains stable.)
A nurse is caring for a client following an arterial vascular bypass graft in the leg. Over the next 24 hours, what should the nurse plan to assess? a) Color of the leg every 4 hours b) Peripheral pulses every 15 minutes following surgery c) Blood pressure every 2 hours d) Ankle-arm indices every 12 hours
d ("Practice meticulous foot care." Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing. Therefore, meticulous foot care is essential. The nurse should teach the client to bathe his feet in warm water and dry them thoroughly, cut the toenails straight across, wear well-fitting shoes, and avoid taking medications without the approval of a physician. Because nicotine is a vasoconstrictor, this client should stop smoking, not just consider cutting down. Daily walking is beneficial to clients with intermittent claudication. To evaluate the effectiveness of the therapeutic regimen, this client should see the physician regularly, not just when complications occur.)
A client complains of leg pain brought on by walking several blocks — a symptom that first arose several weeks earlier. The client's history includes diabetes mellitus and a two-pack-per-day cigarette habit for the past 42 years. The physician diagnoses intermittent claudication and orders pentoxifylline (Trental), 400 mg three times daily with meals. Which instruction concerning long-term care should the nurse provide? a) "Reduce your level of exercise." b) "Consider cutting down on your smoking." c) "See the physician if complications occur." d) "Practice meticulous foot care."
d (The sympathetic nervous system. Stimulation of the sympathetic nervous system causes vasoconstriction thus regulating blood flow. Norepinephrine is the responsible neurotransmitter.)
The most important factor regulating the caliber of blood vessels, which determines resistance to flow, is: a) Hormonal secretion. b) Independent arterial wall activity. c) The influence of circulating chemicals. d) The sympathetic nervous system.
C ("I will call if I develop any coldness, numbness, tingling, or pain in the surgical leg." Correct Explanation: Page 838 The nurse ensures that the patient has the knowledge and ability to assess for any postoperative complications such as infection, occlusion of the artery or graft, and decreased blood flow. Coldness, numbness, tingling, and pain are signs of peripheral arterial occlusion, and immediate intervention is required.)
The nurse completes discharge teaching for a patient following a femoral-to-popliteal bypass graft. What response by the patient would indicate teaching was effective? a) "I can now stop taking my Lipitor because my leg is fixed." b) "I can stop the exercises that were started in the hospital once I return home." c) "I will call if I develop any coldness, numbness, tingling, or pain in the surgical leg." d) "It will important for me to sit at the kitchen table to promote better breathing."
b (1.5 to 2.5 times the baseline control. A normal PTT level is 21 to 35 seconds. A reading of more than 100 seconds indicates a significant risk of hemorrhage.)
When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of: a) 2.5 to 3.0 times the baseline control. b) 1.5 to 2.5 times the baseline control. c) 4.5 times the baseline control. d) 3.5 times the baseline control.
D (Correct response: Participate in a regular walking program. Explanation: p. 831 Clients diagnosed with peripheral arterial occlusive disease should be encouraged to participate in a regular walking program to help develop collateral circulation. They should be advised to rest if pain develops and to resume activity when pain subsides. Extremities should be kept in a dependent position to promote circulation; elevation of the extremities will decrease circulation. Heating pads should not be used by anyone with impaired circulation to avoid burns. Massaging the calf muscles will not decrease pain. Intermittent claudication subsides with rest.)
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? a) Keep the extremities elevated slightly. b) Massage the calf muscles if pain occurs. c) Use a heating pad to promote warmth. d) Participate in a regular walking program.
d (Moderate to severe arterial insufficiency Normal people without arterial insufficiency have an ABI of about 1.0. Those with an ABI of 0.95 to 0.5 have mild to moderate arterial insufficiency. Those with an ABI of less than 0.50 have ischemic rest pain. Those with tissue loss have severe ischemia and an ABI of 0.25 or less.)
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? a) No arterial insufficiency b) Very mild arterial insufficiency c) Tissue loss to that foot d) Moderate to severe arterial insufficiency
B (Moderate to severe arterial insufficiency Correct Explanation: Moderate to severe arterial insufficiency Correct Explanation: p826 Normal people without arterial insufficiency have an ABI of about 1.0. Those with an ABI of 0.95 to 0.5 have mild to moderate arterial insufficiency. Those with an ABI of less than 0.50 have ischemic rest pain. Those with tissue loss have severe ischemia and an ABI of 0.25 or less. Normal people without arterial insufficiency have an ABI of about 1.0. Those with an ABI of 0.95 to 0.5 have mild to moderate arterial insufficiency. Those with an ABI of less than 0.50 have ischemic rest pain. Those with tissue loss have severe ischemia and an ABI of 0.25 or less.)
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? a) Tissue loss to that foot b) Moderate to severe arterial insufficiency c) Very mild arterial insufficiency d) No arterial insufficiency
d (Constant, intense back pain and falling blood pressure Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit.)
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? a) Higher than normal blood pressure and falling hematocrit b) Constant, intense headache and falling blood pressure c) Slow heart rate and high blood pressure d) Constant, intense back pain and falling blood pressure
b (keep the affected leg level or slightly dependent. While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg could cause accidental trauma from cuts or nicks.)
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: a) place a heating pad around the affected calf. b) keep the affected leg level or slightly dependent. c) shave the affected leg in anticipation of surgery. d) elevate the affected leg as high as possible.
C ("It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet." Explanation: p. 831 It is safer to apply a heating pad to the abdomen, causing a reflex vasodilation in the extremities. Heat may be applied directly to ischemic extremities; however, the temperature of the heating source must not exceed body temperature. Excess heat may increase the metabolic rate of the extremities and increase the need for oxygen beyond that provided by the reduced arterial flow through the diseased artery.)
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) "A heating pad to your feet is a good idea because it increases the metabolic rate." b) "It is better to soak your feet in hot water as long as the water temperature is below 110 degrees F." c) "It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet." d) "A heating pad to your feet is fine as long as the temperature stays below 105 degrees F
d ("It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet." It is safer to apply a heating pad to the abdomen, causing a reflex vasodilation in the extremities. Heat may be applied directly to ischemic extremities; however, the temperature of the heating source must not exceed body temperature. Excess heat may increase the metabolic rate of the extremities and increase the need for oxygen beyond that provided by the reduced arterial flow through the diseased artery.)
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) "It is better to soak your feet in hot water as long as the water temperature is below 110 degrees F." b) "A heating pad to your feet is a good idea because it increases the metabolic rate." c) "A heating pad to your feet is fine as long as the temperature stays below 105 degrees F." d) "It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet."
b (Bluish urine Lymphangiography may turn the urine blue temporarily; it doesn't alter stool color. For several months after the procedure, the upper part of the feet may appear blue, not red. Lymphangiography doesn't affect the soles.)
A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless temporary change? a) Purplish stools b) Bluish urine c) Redness of the upper part of the feet d) Coldness of the soles
b (The severity of discomfort isn't related to the size of varicosities. Clients with varicose veins commonly complain of aching, heaviness, itching, moderate swelling, and unsightly appearance of the legs. However, the severity of discomfort is hard to assess and seems unrelated to the size of varicosities. Varicose veins are more common in women than in men. Primary varicose veins typically result from a congenital or familial predisposition that makes the vein wall less elastic; secondary varicosities occur when trauma, obstruction, DVT, or inflammation damages valves. Sclerotherapy, in which a sclerosing agent is injected into a vein, is used to treat varicose veins; it doesn't cure them.)
A client with venous insufficiency develops varicose veins in both legs. Which statement about varicose veins is accurate? a) Sclerotherapy is used to cure varicose veins. b) The severity of discomfort isn't related to the size of varicosities. c) Primary varicose veins are caused by deep vein thrombosis (DVT) and inflammation. d) Varicose veins are more common in men than in women.
C ("I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." The use of tobacco products may be one of the most important risk factors in the development of atherosclerotic lesions. Nicotine in tobacco decreases blood flow to the extremities and increases heart rate and blood pressure by stimulating the sympathetic nervous system. This causes vasoconstriction, thereby decreasing arterial blood flow. It also increases the risk of clot formation by increasing the aggregation of platelets.)
A community health nurse teaches a group of seniors 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 of the following statements? a) "I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels." b) "Since my family is from Italy, I have a higher risk of developing peripheral arterial disease." c) "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." d) "The older I get the higher my risk for peripheral arterial disease gets."
D ("I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." Correct Explanation: P828 The use of tobacco products may be one of the most important risk factors in the development of atherosclerotic lesions. Nicotine in tobacco decreases blood flow to the extremities and increases heart rate and blood pressure by stimulating the sympathetic nervous system. This causes vasoconstriction, thereby decreasing arterial blood flow. It also increases the risk of clot formation by increasing the aggregation of platelets.)
A community health nurse teaches a group of seniors 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 of the following statements? a) "The older I get the higher my risk for peripheral arterial disease gets." b) "Since my family is from Italy, I have a higher risk of developing peripheral arterial disease." c) "I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels." d) "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet."
a (Computed tomography angiography (CTA) A CTA is used to visualize arteries and veins and help assess for stenosis and occlusion.)
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? a) Computed tomography angiography (CTA) b) Magnetic resonance angiography (MRA) c) Doppler ultrasound d) Angiography
b (Venous insufficiency Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gater area, and a reddish blue color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the anterior tibial area. Characteristics of arterial insufficiency ulcers include location at the tips of the toes, great pain, and circular shape with a pale to black ulcer base.)
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? a) Neither venous nor arterial insufficiency b) Venous insufficiency c) Arterial insufficiency d) Trauma
A (Keeping the legs in a neutral or dependent position Correct Explanation: p. 831 Keeping the legs in a neutral or dependent position assists in delivery of arterial blood from the heart to the lower extremities. All the other choices will aid in venous return, but will hinder arterial supply to the lower extremities.)
A home health nurse is teaching a client with peripheral arterial disease ways to improve circulation to the lower extremities. The nurse encourages which of the following in teaching? a) Keeping the legs in a neutral or dependent position b) Elevation of the legs above the heart c) Application of ace wraps from the toe to below the knees d) Use of antiembolytic stockings
a (Keeping the legs in a neutral or dependent position Keeping the legs in a neutral or dependent position assists in delivery of arterial blood from the heart to the lower extremities. All the other choices will aid in venous return, but will hinder arterial supply to the lower extremities.)
A home health nurse is teaching a client with peripheral arterial disease ways to improve circulation to the lower extremities. The nurse encourages which of the following in teaching? a) Keeping the legs in a neutral or dependent position b) Use of antiembolytic stockings c) Elevation of the legs above the heart d) Application of ace wraps from the toe to below the knees
c (Peripheral pulses every 15 minutes following surgery The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the patient's status remains stable.)
A nurse is caring for a client following an arterial vascular bypass graft in the leg. Over the next 24 hours, what should the nurse plan to assess? a) Blood pressure every 2 hours b) Ankle-arm indices every 12 hours c) Peripheral pulses every 15 minutes following surgery d) Color of the leg every 4 hours
a (forcing blood into the deep venous system. Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn't a function of the stockings. Antiembolism stockings could possibly provide warmth, but this factor isn't how they prevent DVT. Elevating the extremity decreases edema but doesn't prevent DVT.)
A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: a) forcing blood into the deep venous system. b) providing warmth to the extremity. c) encouraging ambulation to prevent pooling of blood. d) elevating the extremity to prevent pooling of blood.
A (Intermittent claudication Explanation: , p. 824 Intermittent claudication is leg pain that is brought on by exercise and relieved by rest. Dyspnea is the patient's subjective statement of difficulty breathing. Orthopnea is the inability of the patient to breathe except in the upright (sitting) position. Thromboangiitis obliterans is a peripheral vascular disease also known as Buerger's disease.)
A nurse is teaching a patient newly diagnosed with arterial insufficiency. Which of the following terms should the nurse use to refer to leg pain that occurs when the patient is walking? a) Intermittent claudication b) Thromboangiitis obliterans c) Dyspnea d) Orthopnea
a (Renal failure Renal failure commonly occurs if clamping time is prolonged, cutting off the blood supply to the kidneys. Hemorrhage and shock are the most common complications before abdominal aortic aneurysm resection, and they occur if the aneurysm leaks or ruptures. Graft occlusion and enteric fistula formation are rare complications of abdominal aortic aneurysm repair.)
A nurse should be prepared to manage complications following abdominal aortic aneurysm resection. Which complication is most common? a) Renal failure b) Enteric fistula c) Graft occlusion d) Hemorrhage and shock
C (Explanation: pg 824 Typically, about 50% of the arterial lumen or 75% of the cross-sectional area must be obstructed before intermittent claudication is experienced.)
A nursing instructor is discussing the diagnosis of intermittent claudication with students. To determine if the students understand the pathophysiology of the disease, the instructor asks, "What percentage of the arterial lumen must be obstructed before intermittent claudication is experienced?" a) 40 b) 20 c) 50 d) 30
C (Attempt to palpate the dorsalis pedis and posterior tibial pulses. Explanation: Page 824 Intermittent claudication is a sign of peripheral arterial insufficiency. The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. A thorough assessment of the patient's skin color and temperature and the character of the peripheral pulses are important in the diagnosis of arterial disorders.)
A patient 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? a) Assess for unilateral swelling and tenderness of either leg. b) Ask about any skin color changes that occur in response to cold. c) Attempt to palpate the dorsalis pedis and posterior tibial pulses. d) Check for the presence of tortuous veins bilaterally on the legs.
a (Application of graduated compression stockings Graduated compression stockings usually are prescribed for patients with venous insufficiency. The amount of pressure gradient is determined by the amount and severity of venous disease. Graduated compression stockings are designed to apply 100% of the prescribed pressure gradient at the ankle and pressure that decreases as the stocking approaches the thigh, reducing the caliber of the superficial veins in the leg and increasing flow in the deep veins. These stockings may be knee high, thigh high, or pantyhose.)
A patient is being discharged home with a venous stasis ulcer on the right lower leg. Which topic will the nurse include in patient teaching prior to discharge? a) Application of graduated compression stockings b) Methods of keeping the wound area dry c) Adequate carbohydrate intake d) Prophylactic antibiotic therapy
d (Epinephrine Infrequently, a patient may have an immediate or delayed allergic reaction to the iodine contained in the contrast agent used in angiography. Manifestations include dyspnea, nausea and vomiting, sweating, tachycardia, and numbness of the extremities. Any such reaction must be reported to the interventionalist at once; treatment may include the administration of epinephrine, antihistamines, or corticosteroids.)
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? a) Cimetidine (Tagamet) b) Metoprolol (Lopressor) c) Hydrocortisone (Solu-Cortef) d) Epinephrine
c (The aneurysm may be preparing to rupture. Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Abdominal pain is often localized in the middle or lower abdomen to the left of the midline. Low back pain may be present because of pressure of the aneurysm on the lumbar nerves. Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit. Rupture into the peritoneal cavity is rapidly fatal. A retroperitoneal rupture of an aneurysm may result in hematomas in the scrotum, perineum, flank, or penis.)
A patient with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which of the following is the most likely cause? a) The patient is experiencing normal sensations associated with this condition. b) The aneurysm has become obstructed. c) The aneurysm may be preparing to rupture. d) The patient is experiencing inflammation of the aneurysm.
B (Diminished or absent pulses Explanation:p824 Occlusive arterial disease impairs blood flow and can reduce or obliterate palpable pulsations in the extremities. A diminished or absent pulse is a characteristic of arterial insufficiency.)
The nurse performing an assessment on a patient who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which of the following characteristics? a) Aching, cramping pain b) Diminished or absent pulses c) Pulses are present, may be difficult to palpate d) Superficial ulcer
a, b, d (Postthrombotic syndrome is characterized by chronic venous stasis, resulting in edema, altered pigmentation, pain, and stasis dermatitis. The patient may notice the symptoms less in the morning and more in the evening. Obstruction or poor calf muscle pumping in addition to valvular reflux must be present for the development of severe postthrombotic syndrome and stasis ulcers. Superficial veins may be dilated.)
The nurse is assessing a patient with suspected acute venous insufficiency. What clinical manifestations would indicate this condition to the nurse? (Select all that apply.) a) Sharp pain that may be relieved by the elevation of the extremity b) Full superficial veins c) Initial absence of edema d) Cool and cyanotic skin e) Brisk capillary refill of the toes
a ("Walk to the point of pain, rest until the pain subsides, then resume ambulation." The nurse instructs the patient to walk to the point of pain, rest until the pain subsides, and then resume walking so that endurance can be increased as collateral circulation develops. Pain can serve as a guide in determining the appropriate amount of exercise.)
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? a) "Walk to the point of pain, rest until the pain subsides, then resume ambulation." b) "If you feel pain during the walk, keep walking until the end of the hallway is reached." c) "As soon as you feel pain, we will go back and elevate your legs." d) "If you feel any discomfort, stop and we will use a wheelchair to take you back to your room."
a, c, e (Elevating the legs decreases edema, promotes venous return, and provides symptomatic relief. The legs should be elevated frequently throughout the day (at least 15 to 20 minutes four times daily). At night, the patient should sleep with the foot of the bed elevated about 15 cm (6 inches). Prolonged sitting or standing in one position is detrimental; walking should be encouraged. When sitting, the patient should avoid placing pressure on the popliteal spaces, as occurs when crossing the legs or sitting with the legs dangling over the side of the bed. Constricting garments, especially socks that are too tight at the top or that leave marks on the skin, should be avoided.)
The 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.) a) Sleep with the foot of the bed elevated about 6 inches. b) Sit as much as possible to rest the valves in the legs. c) Avoid constricting garments. d) Sit on the side of the bed and dangle the feet. e) Elevate the legs above the heart level for 30 minutes every 2 hours.
a (Diminished or absent pulses Occlusive arterial disease impairs blood flow and can reduce or obliterate palpable pulsations in the extremities. A diminished or absent pulse is a characteristic of arterial insufficiency.)
The nurse performing an assessment on a patient who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which of the following characteristics? a) Diminished or absent pulses b) Aching, cramping pain c) Pulses are present, may be difficult to palpate d) Superficial ulcer
C (Contrast phlebography Correct Explanation: Page 827 Also known as venography, contrast phlebography involves injecting a radiopaque contrast agent into the venous system. If a thrombus exists, the x-ray image reveals an unfilled segment of vein in an otherwise completely filled vein. Air plethysmography quantifies venous reflux and calf muscle pump ejection. In lymphangiography, contrast media are injected into the lymph system. In a lymphoscintigraphy, a radioactive-labeled colloid is injected into the lymph system. (less).)
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 which of the following? a) Lymphoscintigraphy b) Air plethysmography c) Contrast phlebography d) Lymphangiography
B (Air plethysmography Explanation: p. 827 Air plethysmography is used to quantify venous reflux and calf muscle pump action. Contrast phlebography involves injecting a radiopaque contrast agent into the venous system. Lymphoscintigraphy is done when a radioactively labeled colloid is injected subcutaneously in the second interdigital space. The extremity is then exercised to facilitate the uptake of the colloid by the lymphatic system, and serial images are obtained at present intervals. Lymphoangiography provides a way of detecting lymph node involvement resulting from metastatic carcinoma, lymphoma, or infection in sites that are otherwise inaccessible to the examiner except by surgery.)
Which of the following diagnostic tests are used to quantify venous reflux and calf muscle pump ejection? a) Lymphangiography b) Air plethysmography c) Contrast phlebography d) Lymphoscintigraphy
b (Border regular and well demarcated Characteristics of an arterial ulcer include a border that is regular and demarcated. Brawny edema, ABI > 0.90, and edema that may be severe are characteristics of a venous ulcer.)
Which of the following is a characteristic of an arterial ulcer? a) Brawny edema b) Border regular and well demarcated c) Ankle-brachial index (ABI) > 0.90 d) Edema may be severe
D (Risk factor modification Explanation: Risk factor modification is the most effective intervention for preventing progression of vascular disease. Measures to prevent tissue loss and amputation are a high priority. Patients are taught to avoid trauma; wear sturdy, well-fitting shoes or slippers; and use pH neutral soaps and body lotions.)
Which of the following is the most effective intervention for preventing progression of vascular disease? a) Avoid trauma b) Use neutral soaps c) Wear sturdy shoes d) Risk factor modification
c (Border of the ulcer is irregular The border of an ulcer caused by arterial insufficiency is circular. Superficial venous insufficiency ulcers cause minimal pain. The base of a venous insufficiency ulcer shows beefy red to yellow fibrinous color. Venous insufficiency ulcers are usually superficial.)
Which of the following observations regarding ulcer formation on the patient's lower extremity indicates that the ulcer is a result of venous insufficiency? a) Is deep, involving the joint space b) Base is pale to black c) Border of the ulcer is irregular d) Is very painful to the patient, even though superficial
A (Correct response: Intermittent claudication Explanation: Page 823 Intermittent claudication is a sign of peripheral arterial insufficiency. An aneurysm is a localized sac of an artery wall formed at a weak point in the vessel. A bruit is the sound produced by turbulent blood flow through an irregular, tortuous, stenotic, or dilated vessel. Ischemia is a term used to denote deficient blood supply.)
Which of the following terms refers to a muscular, cramplike pain in the extremities consistently reproduced with the same degree of exercise and relieved by rest? a) Intermittent claudication b) Aneurysm c) Ischemia d) Bruit
