Chapter 37: Vascular Disorders Lewis: Medical-Surgical Nursing, 11th edition

18. The standard policy on the cardiac unit states, Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg. The nurse will need to call the health care provider about the a. postoperative patient with a BP of 116/42. b. newly admitted patient with a BP of 150/87. c. patient with left ventricular failure who has a BP of 110/70. d. patient with a myocardial infarction who has a BP of 140/86.

ANS: A The mean arterial pressure (MAP) is calculated using the formula MAP = (systolic BP + 2 diastolic BP)/3. The MAP for the postoperative patient in answer 1 is 67. The MAP in the other three patients is higher than 70 mm Hg.

16. Which patient statement to the nurse is most consistent with the diagnosis of venous insufficiency? a. "I can't get my shoes on at the end of the day." b. "I can't ever seem to get my feet warm enough." c. "I have burning leg pains after I walk two blocks." d. "I wake up during the night because my legs hurt."

ANS: A Because the edema associated with venous insufficiency increases when the patient has been standing, shoes will feel tighter at the end of the day. The other patient statements are characteristic of peripheral artery disease.

28. The nurse is developing a discharge teaching plan for a patient diagnosed with thromboangiitis obliterans (Buerger's disease). Which expected outcome has the highest priority for this patient? a. Cessation of all tobacco use b. Control of serum lipid levels c. Maintenance of appropriate weight d. Demonstration of meticulous foot care

ANS: A Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with Buerger's disease. Other therapies have limited success in treatment of this disease.

8. When evaluating the discharge teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says, "I will a. use a heating pad on my feet at night to increase the circulation." b. buy some loose clothes that do not bind across my legs or waist." c. walk to the point of pain, rest, and walk again for at least 30 minutes 3 times a week." d. change my position every hour and avoid long periods of sitting with my legs crossed."

ANS: A Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. The other patient statements are correct and indicate that teaching has been successful.

26. The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action should the nurse perform first? a. Obtain vital signs. b. Teach wound care. c. Assess pedal pulses. d. Check the wound site.

ANS: A Bleeding is a possible complication after catheterization of the femoral artery, so the nurse's first action should be to assess for changes in vital signs that might indicate hemorrhage. The other actions are also appropriate but can be done after determining that bleeding is not occurring.

9. After teaching a patient with newly diagnosed Raynaud's phenomenon about how to manage the condition, which action by the patient best demonstrates that the teaching has been effective? a. The patient exercises indoors during the winter months. b. The patient immerses hands in hot water when they turn pale. c. The patient takes pseudoephedrine (Sudafed) for cold symptoms. d. The patient avoids taking nonsteroidal antiinflammatory drugs (NSAIDs).

ANS: A Patients should avoid temperature extremes by exercising indoors when it is cold. To avoid burn injuries, the patient should use warm rather than hot water to warm the hands. Pseudoephedrine is a vasoconstrictor and should be avoided. There is no reason to avoid taking NSAIDs with Raynaud's phenomenon

4. A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which group of drugs will the nurse plan to include when teaching about PAD management? a. Statins b. Antibiotics c. Thrombolytics d. Anticoagulants

ANS: A Research indicates that statin use by patients with PAD improves multiple outcomes. There is no research that supports the use of the other drug categories in PAD.

27. A patient who is 2 days post femoral popliteal bypass graft to the right leg is being cared for on the vascular unit. Which action by a licensed practical/vocational nurse (LPN/LVN) caring for the patient requires the registered nurse (RN) to intervene? a. The LPN/LVN has the patient to sit in a chair for 2 hours. b. The LPN/LVN gives the prescribed aspirin after breakfast. c. The LPN/LVN assists the patient to walk 40 feet in the hallway. d. The LPN/LVN places the patient in Fowler's position for meals.

ANS: A The patient should avoid sitting for long periods because of the increased stress on the suture line caused by leg edema and because of the risk for venous thromboembolism (VTE). The other actions by the LPN/LVN are appropriate.

35. The nurse is admitting a patient newly diagnosed with peripheral artery disease. Which admission order should the nurse question? a. Cilostazol drug therapy b. Omeprazole drug therapy c. Use of treadmill for exercise d. Exercise to the point of discomfort

ANS: B Because the antiplatelet effect of clopidogrel is reduced when it is used with omeprazole, the nurse should clarify this order with the health care provider. The other interventions are appropriate for a patient with peripheral artery disease.

10. When auscultating over the patients abdominal aorta, the nurse hears a humming sound. The nurse documents this finding as a a. thrill. b. bruit. c. murmur. d. normal finding.

ANS: B A bruit is the sound created by turbulent blood flow in an artery. Thrills are palpable vibrations felt when there is turbulent blood flow through the heart or in a blood vessel. A murmur is the sound caused by turbulent blood flow through the heart. Auscultating a bruit in an artery is not normal and indicates pathology.

19. When admitting a patient for a cardiac catheterization and coronary angiogram, which information about the patient is most important for the nurse to communicate to the health care provider? a. The patients pedal pulses are +1. b. The patient is allergic to shellfish. c. The patient had a heart attack a year ago. d. The patient has not eaten anything today.

ANS: B The contrast dye used for the procedure is iodine based, so patients who have shellfish allergies will require treatment with medications such as corticosteroids and antihistamines before the angiogram. The other information is also communicated to the health care provider but will not require a change in the usual precardiac catheterization orders or medications.

20. While working in the outpatient clinic, the nurse notes that a patient has a history of intermittent claudication. Which statement by the patient would support this information? a. "When I stand too long, my feet start to swell." b. "My legs cramp when I walk more than a block." c. "I get short of breath when I climb a lot of stairs." d. "My fingers hurt when I go outside in cold weather."

ANS: B Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication. Finger pain associated with cold weather is typical of Raynaud's phenomenon. Shortness of breath that occurs with exercise is not typical of intermittent claudication, which is reproducible. Swelling associated with prolonged standing is typical of venous disease.

11. The health care provider prescribes an infusion of heparin and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). The nurse will plan to a. decrease the infusion when the PTT value is 65 seconds. b. avoid giving IM medications to prevent localized bleeding. c. have vitamin K available in case reversal of the heparin is needed. d. monitor posterior tibial and dorsalis pedis pulses with the Doppler

ANS: B Intramuscular injections are avoided in patients receiving anticoagulation to prevent hematoma formation and bleeding from the site. A PTT of 65 seconds is within the therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by VTE.

34. The nurse who works in the vascular clinic has several patients with venous insufficiency scheduled today. Which patient should the nurse assign to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Patient who has been complaining of increased edema and skin changes in the legs b. Patient who needs wound care for a chronic venous stasis ulcer on the right lower leg c. Patient who has a history of venous thromboembolism and is complaining of dyspnea d. Patient who needs teaching about elastic compression stockings for venous insufficiency

ANS: B LPN education and scope of practice includes wound care. The other patients, which require more complex assessments or education, should be managed by the RN

12. A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is most accurate? a. "Taking two blood thinners greatly reduces the risk for another clot to form." b. "Enoxaparin will work right away, but warfarin takes several days to begin preventing clots." c. "Enoxaparin will start to dissolve the clot, and warfarin will prevent any more clots from forming." d. "Because of the risk for a blood clot in the lungs, it is important for you to take more than one blood thinner."

ANS: B Low molecular weight heparin (LMWH) is used because of the immediate effect on coagulation and discontinued once the international normalized ratio (INR) value indicates that the warfarin has reached a therapeutic level. LMWH has no thrombolytic properties. The use of two anticoagulants is not related to the risk for pulmonary embolism, and two are not necessary to reduce the risk for another VTE. Anticoagulants do not thin the blood.

13. The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) after hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says which of the following? a. "I should get a Medic Alert device stating that I take warfarin." b. "I should reduce the amount of green, leafy vegetables that I eat." c. "I will need routine blood tests to monitor the effects of the warfarin." d. "I will check with my health care provider before I begin any new drugs."

ANS: B Patients taking warfarin are taught to follow a consistent diet with regard to foods that are high in vitamin K, such as green, leafy vegetables. The other patient statements are accurate.

21. Which instructions should the nurse include in a teaching plan for an older patient newly diagnosed with peripheral artery disease (PAD)? a. "Exercise only if you do not experience any pain." b. "It is very important that you stop smoking cigarettes." c. "Try to keep your legs elevated whenever you are sitting." d. "Put elastic compression stockings on early in the morning."

ANS: B Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death. Circulation to the legs will decrease if the legs are elevated. Patients with PAD are taught to exercise to the point of feeling pain, rest, and then resume walking. Support hose are not used for patients with PAD.

33. Which actions could the nurse delegate to unlicensed assistive personnel (UAP) who are providing care for a patient who is at risk for venous thromboembolism? a. Monitor for any bleeding after anticoagulation therapy is started. b. Apply sequential compression device whenever the patient is in bed. c. Ask the patient about use of herbal medicines or dietary supplements. d. Instruct the patient to call immediately if any shortness of breath occurs.

ANS: B UAP training includes the use of equipment that requires minimal nursing judgment, such as sequential compression devices. Patient assessment and teaching require more education and critical thinking and should be done by the registered nurse (RN).

7. The nurse performing an assessment of a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe would expect to find a. dilated superficial veins. b. swollen, dry, scaly ankles. c. prolonged capillary refill in all the toes. d. serosanguineous drainage from the ulcer

ANS: C Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease

14. A 46-yr-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Which instructions should the nurse provide to the patient before discharge? a. Sitting at the work counter, rather than standing, is recommended. b. Exercise, such as walking or jogging, can cause recurrence of varicosities. c. Elastic compression stockings should be applied before getting out of bed. d. Taking an aspirin daily will help prevent clots from forming around venous valves.

ANS: C Elastic compression stockings are applied with the legs elevated to reduce pressure in the lower legs. Walking is recommended to prevent recurrent varicosities. Sitting and standing are both risk factors for varicose veins and venous insufficiency. An aspirin a day is not adequate to prevent venous thrombosis and would not be recommended for a patient who had just had sclerotherapy.

29. Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? a. Erythema of right lower leg b. Complaint of right calf pain c. New onset shortness of breath d. Temperature of 100.4°F (38°C)

ANS: C New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as O2 administration and notification of the health care provider. The other findings are typical of VTE

19. A young adult patient tells the health care provider about experiencing cold, numb fingers when running during the winter, and Raynaud's phenomenon is suspected. The nurse will anticipate teaching the patient about tests for a. hyperglycemia. b. hyperlipidemia. c. autoimmune disorders. d. coronary artery disease.

ANS: C Secondary Raynaud's phenomenon may occur in conjunction with autoimmune diseases such as rheumatoid arthritis. Patients should be screened for autoimmune disorders. Raynaud's phenomenon is not associated with hyperlipidemia, hyperglycemia, or coronary artery disease.

5. To determine the effects of therapy for a patient who is being treated for heart failure, which laboratory result will the nurse plan to review? a. Troponin b. Homocysteine (Hcy) c. Low-density lipoprotein (LDL) d. B-type natriuretic peptide (BNP)

ANS: D Increased levels of BNP are a marker for heart failure. The other laboratory results would be used to assess for myocardial infarction (troponin) or risk for coronary artery disease (Hcy and LDL).

6. While doing the admission assessment for a thin 76-year-old patient, the nurse observes pulsation of the abdominal aorta in the epigastric area. Which action should the nurse take? a. Teach the patient about aneurysms. b. Notify the hospital rapid response team. c. Instruct the patient to remain on bed rest. d. Document the finding in the patient chart.

ANS: D Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin individuals. The nurse should simply document the finding in the admission assessment. Unless there are other abnormal findings (such as a bruit, pain, or hyper/hypotension) associated with the pulsation, the other actions are not necessary.

32. A patient is being evaluated for postthrombotic syndrome. Which assessment will the nurse perform? a. Ask about leg pain with exercise. b. Determine the ankle-brachial index. c. Assess capillary refill in the patient's toes. d. Inspect for presence of lipodermatosclerosis

ANS: D Clinical signs of postthrombotic syndrome include lipodermatosclerosis. In this situation, the skin on the lower leg becomes scarred, and the leg becomes tapered like an "inverted bottle." The other assessments would be done for patients with peripheral arterial disease

15. Which topic should the nurse include in patient teaching for a patient with a venous stasis ulcer on the left lower leg? a. Need to increase carbohydrate intake b. Methods of keeping the wound area dry c. Purpose of prophylactic antibiotic therapy d. Application of elastic compression stockings

ANS: D Compression of the leg is essential to healing of venous stasis ulcers. High dietary intake of protein, rather than carbohydrates, is needed. Prophylactic antibiotics are not routinely used for venous ulcers. Moist dressings are used to hasten wound healing

6. A patient at the clinic says, "I always walk after dinner, but lately my leg cramps and hurts after just a few minutes of starting. The pain goes away after I stop walking, though." The nurse should a. look for the presence of tortuous veins bilaterally on the legs. b. ask about any skin color changes that occur in response to cold. c. assess for unilateral swelling, redness, and tenderness of either leg. d. palpate for the presence of dorsalis pedis and posterior tibial pulses.

ANS: D The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud's phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness indicate venous thromboembolism.

10. The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venous thromboembolism. Which action by the nurse to elevate the patient's feet is best? a. The patient is placed in the Trendelenburg position. b. Two pillows are positioned under the affected leg. c. The bed is elevated at the knee and pillows are placed under the feet. d. One pillow is placed under the thighs and two pillows are placed under the lower legs.

ANS: D The purpose of elevating the feet is to enhance venous flow from the feet to the right atrium, which is best accomplished by placing two pillows under the feet and one under the thighs. Placing the patient in the Trendelenburg position will lower the head below heart level, which is not indicated for this patient. Placing pillows under the calf or elevating the bed at the knee may cause blood stasis at the calf level.