Chapter 30 Prep U
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? a. Peripheral pulses every 15 minutes after surgery b. Ankle-arm indices every 12 hours c. Blood pressure every 2 hours d. Color of the leg every 4 hours
a 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 client's status remains stable.
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? a. Veins are tied off and removed. b. Removal of the great saphenous vein. c. Veins are tied off and left in the leg. d. Removal of the small saphenous vein.
c A vein ligation is a procedure in which the affected veins are ligated (tied off) above and below the area of incompetent valves, but the dysfunctional vein remains. A vein stripping is the removal of the veins after being tied off.
Which term refers to a muscular, cramp-like pain in the extremities consistently reproduced with the same degree of exercise and relieved by rest? a. Aneurysm b. Bruit c. Intermittent claudication d. Ischemia
c 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.
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 2 days d. In 3 to 5 days
d 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).
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. 1.5 to 2.5 times the baseline control. b. 2.5 to 3.0 times the baseline control. c. 3.5 times the baseline control. d. 4.5 times the baseline control.
a A normal PTT level is 21 to 35 seconds. A reading of more than 100 seconds indicates a significant risk of hemorrhage.
Which term refers to enlarged, red, and tender lymph nodes? a. Lymphadenitis b. Lymphangitis c. Lymphedema d. Elephantiasis
a Acute lymphadenitis is demonstrated by enlarged, red, and tender lymph nodes. Lymphangitis is acute inflammation of the lymphatic channels. Lymphedema is demonstrated by swelling of tissues in the extremities because of an increased quantity of lymph that results from an obstruction of lymphatic vessels. Elephantiasis refers to a condition in which chronic swelling of the extremity recedes only slightly with elevation.
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. Anastomotic b. False c. Dissecting d. Saccular
a 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.
Which aneurysm occurs as a result of infection at arterial suture or graft sites? a. Anastomotic b. False c. Dissecting d. Saccular
a An anastomotic aneurysm occurs as a result of infection, arterial wall failure, and suture or graft failure. 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.
What should the nurse do to manage persistent swelling in a client with severe lymphangitis and lymphadenitis? a. Teach the client how to apply a graduated compression stocking. b. Inform the physician if the client's temperature remains low. c. Avoid elevating the area. d. Offer cold applications to promote comfort and to enhance circulation.
a In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the client how to apply a graduated compression stocking. The nurse informs the physician if the client's temperature remains elevated. The nurse recommends elevating the area to reduce the swelling and provides warmth to promote comfort and to enhance circulation.
A nurse and physician are preparing to visit a hospitalized client with peripheral 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's fingers tingle when left in one position for too long. c. The client experiences shortness of breath after walking about 50 feet. d. The client's legs awaken him during the night with itching.
a 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.
The nurse is caring for a patient who returned from the tropics 2 weeks ago. The patient has been diagnosed with lymphangitis and is experiencing lymphedema. You are aware that the lymphedema may be due to what? a. Obstructed lymph vessels b. Sensitivity to antibiotics c. Excessive lymph is the vascular space d. Improper anticoagulant use
a Lymphedema is caused by accumulation of lymph in the tissues and may be a result of obstructed lymph vessels. It is not caused by sensitivity to antibiotics, vascular accumulation of lymph, or improper anticoagulant use.
The nurse teaches the client with peripheral vascular disease (PVD) to refrain from smoking because nicotine a. causes vasospasm. b. slows the heart rate. c. depresses the cough reflex. d. causes diuresis.
a Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities. Nicotine has stimulant effects. Nicotine does not suppress cough; rather, smoking irritates the bronchial tree, causing coughing. Nicotine does not cause diuresis.
Health teaching includes advising patients on ways to reduce PAD. The nurse should always emphasize that the strongest risk factor for the development of atherosclerotic lesions is: a. Cigarette smoking. b. Lack of exercise. c. Obesity. d. Stress.
a Nicotine decreases blood flow, increases heart rate and blood pressure, and increases the risk for clot formation by increasing platelet aggregation. Smokers have a four-fold higher risk of developing pain from arterial disease than nonsmokers. Carbon monoxide, produced by burning tobacco, combines with hemoglobin more readily than oxygen, thus depriving tissues of oxygen.
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? a. Stop smoking. b. Keep your feet elevated above your heart. c. Wear antiembolic stockings daily to assist with blood return to the heart. d. Do not cross your legs for more than 30 minutes at a time.
a Nicotine from tobacco products causes vasospasm and can thereby dramatically reduce circulation to the extremities. When the client elevates the feet above the heart level, the heart must work against gravity to supply blood to the feet. Antiembolic stocking are helpful for venous return to the heart, but constriction is not helpful for lack of arterial blood flow. Crossing the legs for more than a few minutes at a time compresses arteries and decreases blood supply to the legs and feet.
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. Moderate to severe arterial insufficiency b. No arterial insufficiency c. Very mild arterial insufficiency d. Tissue loss to that foot
a 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.
Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending? a. Increased abdominal and back pain b. Decreased pulse rate and blood pressure c. Retrosternal back pain radiating to the left arm d. Elevated blood pressure and rapid respirations
a 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.
A patient with impaired renal function is scheduled for a multidetector computer tomography (MDCT) scan. What preprocedure medication may the nurse administer to this patient? a. Oral N-acetylcysteine b. Oral iodine c. Dipyridamole (Persantine) d. Epinephrine
a Patients with impaired renal function scheduled for MDCT may require preprocedural treatment to prevent contrast-induced nephropathy. This may include oral or IV hydration 12 hours preprocedure; administration of oral N-acetylcysteine, which acts as an antioxidant; and/or administration of sodium bicarbonate, which alkalinizes urine and protects against free radical damage (Rundback, Nahl, & Yoo, 2011).
Which of the following is the most effective intervention for preventing progression of vascular disease? a. Risk factor modification b. Use neutral soaps c. Avoid trauma d. Wear sturdy shoes
a 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.
A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment? a. Numbness, cool skin temperature, and pallor b. Swelling, warm skin temperature, and drainage c. Numbness, warm skin temperature, and redness d. Redness, cool skin temperature, and swelling
a Signs and symptoms of impaired circulation include numbness and cool, pale skin. Signs of localized infection may include swelling, drainage, redness, and warm skin. Signs of adequate circulation include normal sensation and warm skin with normal return of skin color after blanching.
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? a. Taking daily walks b. Engaging in anaerobic exercise c. Reducing daily fat intake to less than 45% of total calories d. Abstaining from foods that increase levels of high-density lipoproteins (HDLs)
a Taking daily walks relieves symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may make these symptoms worse. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat, not abstain from, foods that raise HDL levels.
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 thermoregulation d. Ineffective self-health management
a The goal is to increase arterial blood supply to the extremities; the priority nursing diagnosis is Ineffective peripheral tissue perfusion related to compromised circulation.
Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity? a. Intermittent claudication b. Acute limb ischemia c. Dizziness d. Vertigo
a The hallmark symptom of PAD in the lower extremity is intermittent claudication. This pain may be described as aching or cramping in a muscle that occurs with the same degree of exercise or activity and is relieved with rest. Acute limb ischemia is a sudden decrease in limb perfusion, which produces new or worsening symptoms that may threaten limb viability. Dizziness and vertigo are associated with upper extremity arterial occlusive disease.
The nurse assesses a patient with hip pain related to intermittent claudication. She knows that the area of arterial narrowing is the: a. Common iliac artery. b. Common femoral artery. c. Anterior tibial. d. Posterior tibial.
a The location of the claudication occurs in muscle groups distal to the diseased vessel. Hip or buttock pain may result from reduced blood flow from the common iliac artery.
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. keep the client warm. b. maintain room temperature at 78° F (25.6° C). c. keep the client uncovered. d. match the room temperature to the client's body temperature.
a 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.
Which of the following is the most common site for a dissecting aneurysm? a. Thoracic area b. Lumbar area c. Sacral area d. Cervical area
a The thoracic area is the most common site for a dissecting aneurysm. About one-third of patients with thoracic aneurysms die of rupture of the aneurysm.
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? a. "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." b. "I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels." c. "The older I get the higher my risk for peripheral arterial disease gets." d. "Because my family is from Italy, I have a higher risk of developing peripheral arterial disease."
a 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.
Which class of medication lyses and dissolves thrombi? a. Fibrinolytic b. Anticoagulant c. Platelet inhibitors d. Factor XA inhibitors
a Thrombolytic (fibrinolytic) therapy lyses and dissolves thrombi in 50% of clients. Anticoagulants, platelet inhibitors, and factor XA inhibitors do not lyse or dissolve thrombi.
A patient is suspected to have a thoracic aortic aneurysm. What diagnostic test(s) does the nurse anticipate preparing the patient for? (Select all that apply.) a. Computed tomography b. Transesophageal echocardiography c. X-ray d. Electroencephalogram e. Electrocardiogram (ECG)
a, b, c Diagnosis of a thoracic aortic aneurysm is principally made by chest x-ray, computed tomography angiography (CTA), and transesophageal echocardiography (TEE).
Which of the following are complications of percutaneous transluminal balloon angioplasty (PTA)? Select all that apply. a. Hematoma b. Embolization c. Dissection of the vessel d. Bleeding e. Stent migration
a, b, c, d, e PTA is used to treat artherosclerosis. A balloon-tipped catheter is maneuvered across the area of stenosis, and a stent (small mesh tube) may be inserted to support the blood vessel walls and prevent collapse. Complications from PTA include hematoma, embolization, dissection of the vessel, bleeding, intimal damage (dissection), and stent migration.
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. Cool and cyanotic skin b. Initial absence of edema c. Sharp pain that may be relieved by the elevation of the extremity d. Full superficial veins e. Brisk capillary refill of the toes
a, c, 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 assessing a client who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which characteristic? a. Diminished or absent pulses b. Superficial ulcer c. Aching, cramping pain d. Pulses that are present but difficult to palpate
a. 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.
A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? a. Urine output of 15 ml/hour and 2+ hematuria b. Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute c. Urine output of 150 ml/hour and heart rate of 45 beats/minute d. Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute
b Assessment findings that indicate possible bleeding or recurring dissection include hypotension with reflex tachycardia (as evidenced by a blood pressure of 82/40 mm Hg and a heart rate of 125 beats/minute), decreased urine output, and unequal or absent peripheral pulses. Hematuria, increased urine output, and bradycardia aren't signs of bleeding from aneurysm repair or recurring dissection.
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. Participate in a regular walking program. c. Use a heating pad to promote warmth. d. Massage the calf muscles if pain occurs.
b 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.
The nurse knows which diagnostic test is used to document the anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux? a. Contrast phlebography b. Duplex ultrasound scan c. Lymphangiography d. Lymphoscintigraphy
b Diagnostic tests for varicose veins include the duplex ultrasound scan, which documents the anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux. 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 preset intervals. Lymphangiography provides a way to detect lymph node involvement resulting from metastatic carcinoma, lymphoma, or infection in sites that are otherwise inaccessible to the examiner except by surgery.
What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue? a. Loose and wrinkled skin b. Ulcers and infection in the edematous area c. Evident scaring d. Cyanosis
b In a client with lymphedema, the tissue nutrition is impaired as a result of the stagnation of lymphatic fluid, leading to ulcers and infection in the edematous area. Later, the skin also appears thickened, rough, and discolored. Scaring does not occur in clients with lymphedema. Cyanosis is a bluish discoloration of the skin and mucous membranes.
With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by: a. Elevating the limb over the heart level. b. Lowering the limb so that it is dependent. c. Massaging the limb after application of cold compresses. d. Placing the limb in a plane horizontal to the body.
b Lowering the extremity to a dependent position improves perfusion to the distal tissues.
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 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.
The nurse is performing wound care for a patient with a necrotic sacral wound. The prescribed treatment is isotonic saline solution with fine mesh gauze and a dry dressing to cover. What type of debridement is the nurse performing? a. Surgical debridement b. Nonselective debridement c. Enzymatic debridement d. Selective debridement
b Nonselective débridement can be accomplished by applying isotonic saline dressings of fine mesh gauze to the ulcer. When the dressing dries, it is removed (dry), along with the debris adhering to the gauze. Pain management is usually necessary.
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? a. Report changes in the usual pattern of chest pain. b. Avoid situations that contribute to ischemic episodes. c. Avoid fatty foods and exercise. d. Take over-the-counter decongestants.
b Teaching for clients with Raynaud's disease and their family members is important. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants.
When teaching a client with peripheral vascular disease about foot care, a nurse should include which instruction? a. Avoid using cornstarch on the feet. b. Avoid wearing canvas shoes. c. Avoid using a nail clipper to cut toenails. d. Avoid wearing cotton socks.
b The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, and perspiration can cause skin irritation and breakdown. Cotton and cornstarch absorb perspiration. The client should be instructed to cut toenails straight across with nail clippers.
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 a. air plethysmography. b. contrast phlebography. c. lymphangiography. d. lymphoscintigraphy.
b When a thrombus exists, an x-ray image will disclose an unfilled segment of a 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.
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? a. Coronary artery disease b. Aortic aneurysm c. Raynaud's disease d. Peripheral artery disease
b. A pulsating mass may be felt or even seen around the umbilicus or to the left of midline over the abdomen. Options A, C, and D would not present with a pulsating mass near the umbilicus; therefore, they are incorrect.
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? a. Aneurysm b. Coronary thrombosis c. Atherosclerosis d. Raynaud's disease
c Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. Therefore, options A, B, and D are incorrect.
Which risk factor is related to venous stasis for deep vein thrombosis (DVT) and pulmonary embolism (PE)? a. Trauma b. Pacing wires c. Obesity d. Surgery
c Obesity is a risk factor for DVT and PE related to venous stasis. Trauma, pacing wires, and surgery are related to endothelial damage as a risk factor for DCAT and PE.
When caring for a patient with leg ulcers, the positioning of the legs depends on whether the patient's ulcer is arterial or venous in origin. How should the nurse position a patient who has leg ulcers that are venous in origin? a. Keep the patient's legs flat without the knees raised. b. Keep the patient's knees at a 45-degree angle. c. Elevate the patient's lower extremities. d. Hang the patient's legs over the side of the bed
c Positioning of the legs depends on whether the ulcer is of arterial or venous origin. If there is venous insufficiency, dependent edema can be avoided by elevating the lower extremities. Bending the knees, keeping the legs flat, and dangling the patient's legs may exacerbate the condition.
The nurse is working with a client who has just been diagnosed with an aneurysm. What advice should the nurse provide to this client? a. Minimize bowel movements and coughing. b. Avoid situations that contribute to ischemic episodes. c. Avoid straining during bowel movements and coughing. d. Wear wool socks and mittens during cold weather.
c The nurse advises the client with an aneurysm to avoid straining during bowel movements and coughing. The client with Raynaud's disease is asked to avoid situations that contribute to ischemic episodes and to wear wool socks and mittens during cold weather.
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. "As soon as you feel pain, we will go back and elevate your legs." b. "If you feel pain during the walk, keep walking until the end of the hallway is reached." c. "Walk to the point of pain, rest until the pain subsides, then resume ambulation." d. "If you feel any discomfort, stop and we will use a wheelchair to take you back to your room."
c 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.
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? a. Elevate the legs periodically for at least an hour. b. Avoid foods with iodine. c. Elevate the legs periodically for at least 15 to 20 minutes. d. Refrain from sexual activity for a week.
c The nurse should advise the client to periodically elevate the legs for at least 15 to 20 minutes. Avoiding foods with iodine or refraining from sexual activity for a week does not relate to venous insufficiency.
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. Doppler ultrasound b. Magnetic resonance angiography (MRA) c. Angiography d. Computed tomography angiography (CTA)
d A CTA is used to visualize arteries and veins and help assess for stenosis and occlusion.
A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures? a. "I like to soak my feet in the hot tub every day." b. "I walk only to the mailbox in my bare feet." c. "I stopped smoking and use only chewing tobacco." d. "I have my wife look at the soles of my feet each day."
d A client with peripheral vascular disease should examine his feet daily for redness, dryness, or cuts. If a client isn't able to do this examination on his own, then a caregiver or family member should help him. A client with peripheral vascular disease should avoid hot tubs because decreased sensation in the feet may make him unable to tell if the water is too hot. The client should always wear shoes or slippers on his feet when he is out of bed to help minimize trauma to the feet. Any type of nicotine, whether it's from cigarettes or smokeless tobacco, can cause vasoconstriction and further decrease blood supply to the extremities.
The physician prescribed a Tegapore dressing to treat a venous ulcer. What should the nurse expect that the ankle-brachial index (ABI) will be if the circulatory status is adequate? a. 0.10 b. 0.25 c. 0.35 d. 0.50
d After the circulatory status has been assessed and determined to be adequate for healing (ABI of more than 0.5) (Mosti, Iabichella, & Partsch, 2012), surgical dressings can be used to promote a moist environment.
A 56-year-old woman with severe varicose veins has opted for venous ablation, and the nurse is providing patient education before the scheduled procedure. What instructions should the nurse provide to this patient? a. "Try to limit your activity for the first 10 days to 2 weeks to prevent reoccurrence of your varicose veins." b. "You might experience some pain after the procedure, but this will be managed with ice packs rather than medications." c. "If you notice any bruising in the area, make sure to let someone know because that could be a sign of a serious complication." d. "We'll help you get walking as soon as you sedation has worn off, and you'll continue to gradually increase your activity level."
d After venous ablation procedures, bed rest is discouraged; the nurse encourages the patient to become ambulatory as soon as sedation has worn off. The patient is instructed to walk according to an individual protocol, and to increase walking and activity as tolerated. Pain management strategies include appropriate analgesics, and bruising is to be expected.
A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: a. encouraging ambulation to prevent pooling of blood. b. providing warmth to the extremity. c. elevating the extremity to prevent pooling of blood. d. forcing blood into the deep venous system.
d 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 teaching a client who will soon be discharged with a prescription for warfarin (Coumadin). Which statement should the nurse include in discharge teaching? a. "Eat more yogurt and broccoli." b. "This drug will dissolve any clots you may still have." c. "If you miss a dose, double the next dose." d. "Don't take aspirin while you're taking warfarin."
d Because aspirin decreases platelet aggregation and interferes with clotting, concomitant use of aspirin with warfarin, an anticoagulant, may lead to excessive anticoagulant effects — and bleeding. Warfarin therapy is most effective with consistent dietary intake of vitamin K. Increase intake of foods rich in vitamin K, such as broccoli, could change the client's warfarin dose requirements. Although warfarin interrupts the normal clotting cycle, it doesn't dissolve clots that have already formed. The client should take warfarin exactly as ordered to maintain the desired level of anticoagulation. Doubling a dose could cause bleeding.
When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe? a. Painful skin that is swollen and pale in color b. Cold, red skin c. Small, localized blackened area of skin d. Red, swollen skin with inflammation spreading to surrounding tissues
d Cellulitis, an inflammation of soft tissues, can extend to surrounding tissues. The skin becomes reddened, warm, swollen, and sometimes painful. The skin wouldn't be cold, pale, or necrotic.
Which statement is accurate regarding Raynaud disease? a. The disease generally affects the client trilaterally. b. It affects more than two digits on each hand or foot. c. It is most common in men 16 to 40 years of age. d. Episodes may be triggered by unusual sensitivity to cold.
d Episodes of Raynaud disease may be triggered by emotional factors or by unusual sensitivity to cold. The disease is most common in women between 16 and 40 years of age. It is generally unilateral and affects only one or two digits.
A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? a. Impaired gas exchange related to increased blood flow b. Excess fluid volume related to peripheral vascular disease c. Risk for injury related to edema d. Ineffective peripheral tissue perfusion related to venous congestion
d Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with DVT. Impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Excess fluid volume related to peripheral vascular disease is inappropriate because there's no evidence that this client has an excess fluid volume. Risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion.
A nurse is teaching a client newly diagnosed with arterial insufficiency. Which term should the nurse use to refer to leg pain that occurs when the client is walking? a. Dyspnea b. Orthopnea c. Thromboangiitis obliterans d. Intermittent claudication
d Intermittent claudication is leg pain that is brought on by exercise and relieved by rest. Dyspnea is difficulty breathing and is subjective. Orthopnea is the inability to breathe except in the upright (sitting) position. Thromboangiitis obliterans is a peripheral vascular disease also known as Buerger disease.
Following abdominal surgery, which factor predisposes a client to deep vein thrombosis? a. The client is 5' 9" tall and weighs 128 lb (58 kg). b. The client has been pregnant four times. c. The client usually walks 3 miles a day. d. The client will be immobile during and shortly after surgery.
d Postoperative immobility and subsequent venous stasis predispose the client to deep vein thrombosis. Other predisposing factors for this condition include obesity and current pregnancy, which don't apply to this client. Exercise isn't a risk factor for deep vein thrombosis.
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: a. reduces stress. b. aids in weight reduction. c. increases high-density lipoprotein (HDL) level. d. decreases venous congestion.
d Regular walking is the best way to decrease venous congestion because using the leg muscles as a pump helps return blood to the heart. Regular exercise also aids in stress reduction and weight reduction and increases the formation of HDLs — which are all beneficial to a client with peripheral vascular disease. However, these changes don't have as significant an effect on the client's condition as decreasing venous congestion.
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. pallor and coolness of the left foot. b. a decrease in the left pedal pulse. c. loss of hair on the lower portion of the left leg. d. left calf circumference 1" (2.5 cm) larger than the right.
d 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.
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.
d Stimulation of the sympathetic nervous system causes vasoconstriction thus regulating blood flow. Norepinephrine is the responsible neurotransmitter.
To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the: a. Inside of the ankle just above the heel. b. Exterior surface of the foot near the heel. c. Outside of the foot just below the heel. d. Anterior surface of the foot near the ankle joint.
d The dorsalis pedis pulse can be palpated on the dorsal surface of the foot distal to the major prominence of the navicular bone.
A nursing instructor is discussing the diagnosis of intermittent claudication with students. To determine whether 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?" What answer should the students give? a. 20 b. 30 c. 40 d. 50
d Typically, about 50% of the arterial lumen or 75% of the cross-sectional area must be obstructed before intermittent claudication is experienced.
The nurse is caring for a patient with venous insufficiency. For what should the nurse assess the patient's lower extremities? a. Rubor b. Cellulitis c. Dermatitis d. Ulceration
d Venous ulceration is the most serious complication of chronic venous insufficiency and can be associated with other conditions affecting the circulation of the lower extremities. Cellulitis or dermatitis may complicate the care of chronic venous insufficiency and venous ulcerations.
A community health nurse is providing dressing changes for an older adult woman who has a chronic venous ulcer. When choosing a wound management strategy for this patient, what principle should guide the nurse's care regimen? a. Dead tissue should remain undisturbed and allowed to naturally resorb. b. Topical antibiotics should be kept in contact with the wound bed at all times. c. Wound healing will occur most quickly if the wound bed is kept as moist as possible. d. The wound exudate should be promptly removed from the wound bed.
d Venous ulcers with necrotic tissue should be debrided. To promote healing, the wound is kept clean of drainage. Topical antibiotics have been shown to be of little benefit.
The nurse is caring for a client who is status post operative from a vein stripping. What would the nurse monitor for? a. Swelling in the inoperative leg b. Blood on the dressing on the inoperative leg c. Warm, pink toes in the inoperative leg d. Swelling in the operative leg
d When the client returns from surgery with a gauze dressing covered by elastic roller bandages on the operative leg, the nurse monitors for swelling in the operative leg(s) and its effect on circulation.
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: a. Internal iliac. b. Common femoral. c. Popliteal. d. Posterior tibial.
d. Clinical symptoms of PAD are manifested in organs or muscle groups supplied by specific arterial blood flow. The posterior tibial artery is a major artery that is a common site for occlusion.
