Chapter 41: Vascular Problems
When assessing a patient with possible peripheral artery disease (PAD), the nurse obtains a brachial blood pressure (BP) of 154/82 mm Hg and an ankle pressure of 112/74 mm Hg. The nurse calculates the patient's ankle-brachial index (ABI) as ________ (round up to the nearest hundredth).
ANS: 0.73 The ABI is calculated by dividing the ankle systolic BP by the brachial systolic BP.
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.
Which patient statement is consistent with their experiencing 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 pain 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.
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 would 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 would 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 the patient is breathing and hemodynamically stable.
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/VN) caring for the patient requires the registered nurse (RN) to intervene? a. The LPN/VN tells the patient sit in a chair for 2 hours. b. The LPN/VN gives the prescribed aspirin after breakfast. c. The LPN/VN assists the patient to walk 40 ft in the hallway. d. The LPN/VN places the patient in Fowler's position for meals.
ANS: A Discourage the patient from prolonged sitting with legs lowered, since it may cause pain and edema, increase the risk for venous thrombosis, and place stress on the suture lines. The other actions by the LPN/LVN are appropriate.
Which action by the patient with newly diagnosed Raynaud's phenomenon demonstrates that the nurse's teaching about managing the condition 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.
Which group of drugs will the nurse plan to include when teaching a patient who has a new diagnosis of peripheral artery disease (PAD)? a. Statins b. Antibiotics c. Thrombolytics d. Anticoagulants
ANS: A Statin use by patients with PAD improves multiple outcomes; aggressive lipid management is needed for all patients with PAD. Antibiotics are not needed as PAD is not associated with infection. Thrombolytics and/or anticoagulants may be used in treatment of acute arterial occlusion, but are not part of general management of PAD.
Which action would the nurse include in the plan of care for a patient after endovascular repair of an abdominal aortic aneurysm? a. Record hourly chest tube drainage. b. Monitor fluid intake and urine output. c. Assess the abdominal incision for redness. d. Counsel the patient to plan for a long recovery time
ANS: B Because renal artery occlusion can occur after endovascular repair, the nurse should monitor parameters of renal function such as intake and output. Chest tubes will not be needed for endovascular surgery, the recovery period will be short, and there will not be an abdominal wound
The nurse is admitting a patient newly diagnosed with peripheral artery disease who takes clopidogrel. Which admission order would 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.
An older patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which action would the nurse take first? a. Draw blood for laboratory testing. b. Check the patient's blood pressure. c. Assess the patient for an abdominal bruit. d. Determine any family history of heart disease.
ANS: B Because the patient appears to be experiencing aortic dissection, the nurse's first action should be to determine the hemodynamic status by assessing blood pressure. The other actions may also be done, but they will not provide information to determine what interventions are needed immediately.
The nurse is evaluating the discharge teaching outcomes for a patient with chronic peripheral artery disease (PAD). Which patient statement indicates a need for further instruction? a. ―I will buy loose clothes that do not bind across my legs or waist.‖ b. ―I will use a heating pad on my feet at night to increase the circulation.‖ c. ―I will walk to the point of pain, rest, and walk again for at least 30 minutes 3 times a week.‖ d. ―I will change my position every hour and avoid long periods of sitting with my legs crossed.‖
ANS: B 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.
Which patient statement supports a history of intermittent claudication? 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.
Which finding on a patient's nursing admission assessment is congruent with the initial medical diagnosis of a 6-cm thoracic aortic aneurysm? a. Low back pain b. Difficulty swallowing c. Abdominal tenderness d. Changes in bowel habits
ANS: B Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the esophagus. The other symptoms would be expected in patients with abdominal aortic aneurysms.
Which risk factor would the nurse focus on when teaching a patient who has a 5-cm abdominal aortic aneurysm? a. Male gender b. Hypertension c. Age over 60 years d. Family history of vascular disease
ANS: B Hypertension can potentially be managed to decrease the patient's risk for further expansion of the aneurysm. Male gender, older age, and family history are not modifiable risk factors.
Which action would the nurse take when giving fondaparinux (Arixtra) to a patient with a lower leg venous thromboembolism (VTE)? a. Massage the site after giving the injection. b. Inject the drug into the abdominal subcutaneous tissue. c. Ejects the air bubble from the syringe before giving the drug. d. Check partial thromboplastin time (PTT) before giving the drug.
ANS: B Low-molecular-weight heparin (LMWH) is administered subcutaneously in the abdominal area. The air bubble is not ejected before giving fondaparinux to avoid loss of drug. The other actions by the nurse are appropriate for LMWHs typically do not require ongoing PTT monitoring and dose adjustment.
A patient with a venous thromboembolism (VTE) has new prescriptions for enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is accurate? a. ―Taking two medications dissolves the blood clot much faster.‖ b. ―Enoxaparin works right away, but warfarin takes several days to prevent 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, usually about 5 days. LMWH and warfarin have no thrombolytic properties and they do not dissolve clots. The use of two anticoagulants is not related to the risk for pulmonary embolism.
The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action would the nurse take first? a. Wrap both legs in a warming blanket. b. Notify the surgeon and anesthesiologist. c. Document the findings and recheck in 15 minutes. d. Review the preoperative assessment in the health record.
ANS: B Lower extremity pulses may be absent for a short time after surgery because of vasospasm and hypothermia. Decreased or absent pulses together with a cool and mottled extremity may indicate embolization or graft occlusion. These findings would be reported to the surgeon immediately because this is an emergency situation. Because pulses are marked before surgery, the nurse already would know whether pulses were present before surgery. Because the patient's symptoms may indicate graft occlusion or multiple emboli and a possible need to return to surgery, it is not appropriate to wait 15 minutes before taking action. A warming blanket will not improve the circulation to the patient's legs.
Which instructions would the nurse include in a teaching plan for an older adult 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.
The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) after hospitalization for venous thromboembolism (VTE). Which patient statement indicates a need for additional teaching? 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 Teach patients taking warfarin to follow a consistent diet regarding foods that are high in vitamin K, such as green, leafy vegetables. There is no need to reduce the intake of these vegetables. The other patient statements are accurate.
A patient had an open surgical repair of an abdominal aortic aneurysm earlier today. The patient's total urinary output for the past 2 hours was 45 mL. What would the nurse anticipate will be prescribed? a. Hemoglobin count b. Increased IV fluids c. Additional antibiotics d. Serum creatinine level
ANS: B The decreased urine output suggests decreased renal perfusion and monitoring of renal function is needed. There is no indication that infection is a concern, so antibiotic therapy and a WBC count are not needed. The IV rate may be increased because hypovolemia may be contributing to the patient's decreased urinary output.
After receiving change-of-shift report, which patient admitted to the emergency department would the nurse assess first? a. A 67-yr-old patient who has a gangrenous foot ulcer with a weak pedal pulse b. A 50-yr-old patient who is reporting sudden sharp and severe upper back pain c. A 39-yr-old patient who has right calf tenderness and swelling after a plane ride d. A 58-yr-old patient taking anticoagulants for atrial fibrillation who has black stools
ANS: B The patient's presentation of sudden sharp and severe upper back pain is consistent with dissecting thoracic aneurysm, which will require the most rapid intervention. The other patients also require rapid intervention but not before the patient with severe pain.
Which action for a patient at risk for venous thromboembolism could the nurse delegate to assistive personnel (AP)? a. Monitor for any bleeding after anticoagulation therapy is started. b. Tell the patient to call immediately if any shortness of breath occurs. c. Apply sequential compression devices whenever the patient is in bed. d. Ask the patient about use of any herbal medicines or dietary supplements.
ANS: C AP 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)
A patient has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe. Which assessment finding would the nurse expect? 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 manifestations are consistent with chronic venous disease.
A patient is being evaluated for postthrombotic syndrome. Which assessment will the nurse perform? a. Ask about pain with leg elevation. b. Determine the ankle-brachial index. c. Inspect for edema and color changes. d. Assess capillary refill in the patient's toes.
ANS: C Clinical signs of postthrombotic syndrome include persistent edema, spider veins (telangiectasia), venous dilation (ectasia), redness, cyanosis, increased pigmentation, eczema, pain during compression, atrophie blanche (white scar tissue). The other assessments would be done for patients with peripheral arterial disease.
An adult whose employment requires long periods of standing undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Which instructions would 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.
The health care provider prescribes heparin infusion and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). Which action would the nurse include in the plan of care? a. Obtain a Doppler for monitoring bilateral pedal pulses. b. Decrease the infusion when the PTT value is 65 seconds. c. Avoid giving IM medications to prevent localized bleeding. d. Have vitamin K available in case reversal of the heparin is needed.
ANS: C 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.
The nurse who works in the vascular clinic has several patients with venous insufficiency. Which patient would the nurse assign to an experienced licensed practical/vocational nurse (LPN/VN)? a. Patient who has a history of venous thromboembolism and reports dyspnea. b. Patient who has been reporting increased edema and skin changes in the legs. c. Patient who needs wound care for a chronic venous stasis ulcer on the lower leg. d. Patient who needs teaching about compression stockings for venous insufficiency.
ANS: C 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.
When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider? a. Presence of flatus b. Hypoactive bowel sounds c. Maroon-colored liquid stool d. Abdominal pain with palpation
ANS: C Loose, bloody (maroon-colored) stools at this time may indicate intestinal ischemia or infarction and would be reported immediately because the patient may need an emergency bowel resection. The other findings are normal on the first postoperative day after abdominal surgery.
Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse? a. Report of right calf pain b. Redness of right lower leg c. New onset shortness of breath d. Temperature of 100.4F (38C)
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.
A young adult patient tells the health care provider about having cold, numb fingers. After Raynaud's phenomenon is diagnosed, which condition would the nurse anticipate as a likely comorbidity? a. Hyperglycemia b. Hyperlipidemia c. Coronary artery disease d. Systemic lupus erythematosus
ANS: C Secondary Raynaud's phenomenon may occur in conjunction with autoimmune diseases such as systemic lupus erythematosus. Patients should be screened for autoimmune disorders. Raynaud's phenomenon is not associated with hyperlipidemia, hyperglycemia, or coronary artery disease.
The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with a venous thromboembolism of the left lower leg. Which action would the nurse take? a. Place a rolled towel under the patient's left ankle. b. Place the patient's bed in the Trendelenburg position. c. Place a pillow under the thighs and 2 pillows under the lower legs. d. Elevate the bed at the head and knee and place pillows under both feet.
ANS: C The purpose of elevating the feet is to enhance venous flow from the feet to the right atrium, which is best accomplished by placing 2 pillows under the feet and another under the thighs. Placing the patient in the Trendelenburg position will lower the head below heart level, which is not indicated for this patient. Elevating the bed at the head and knee may cause blood stasis at the calf level. A rolled towel under the ankle may help prevent heel pressure but will not improve venous return.
The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider? a. Weak pedal pulses b. Absent bowel sounds c. Blood pressure of 148/88 mm Hg d. 25 mL of urine output over the past hour
ANS: C The systolic blood pressure is typically kept between 100- and 110-mmHg to minimize extension of the dissection. The nurse will need to notify the health care provider so that b-blockers or other antihypertensive drugs can be prescribed. The other findings are typical with aortic dissection and would also be reported but do not require immediate action.
Which intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously could the nurse delegate to assistive personnel (AP)? a. Monitor the quality and presence of the pedal pulses. b. Teach the patient the signs of possible wound infection. c. Check the lower extremities for strength and movement. d. Help the patient to use a pillow to splint while coughing.
ANS: D Assisting a patient who has already been taught how to cough is part of routine postoperative care and within the education and scope of practice for UAP. Patient teaching and assessment of essential postoperative functions such as circulation and movement would be done by RNs.
Which topic would the nurse include in teaching for a patient with a venous stasis ulcer on the 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 graduated compression stockings
ANS: D Graduated 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.
A patient at the clinic says, ―I always walk after dinner, but lately my leg cramps and hurts after just a few minutes. The pain goes away after I stop walking, though.‖ Which focused assessment would the nurse make? 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.
An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. After the nurse notifies the health care provider, what would the nurse do next? a. Apply a compression stocking to the leg. b. Elevate the leg above the level of the heart. c. Assist the patient in gently exercising the leg. d. Keep the patient in bed in the supine position.
ANS: D The patient's history and clinical manifestations are consistent with acute arterial occlusion. Resting the leg will decrease the O2 demand of the tissues and minimize ischemic damage until circulation can be restored. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the leg.