PrepU PVD Chapter 30 Questions
When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of:
1.5 to 2.5 times the baseline control. Explanation: A normal PTT level is 21 to 35 seconds. A reading of more than 100 seconds indicates a significant risk of hemorrhage.
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?
Anastomotic Explanation: 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.
To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the:
Anterior surface of the foot near the ankle joint.
Pentoxifylline (Trental) is a medication used for which of the following conditions?
Claudication
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?
Constant, intense back pain and falling blood pressure. Explanation: Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit.
Which of the following are characteristics of arterial insufficiency?
Diminished or absent pulses. Explanation: A diminished or absent pulse is a characteristic of arterial insufficiency. Venous characteristics include superficial ulcer formation, an aching and cramping pain, and presence of pulses.
Which of the following aneurysms results in bleeding into the layers of the arterial wall?
Dissecting Explanation: Dissection results from a rupture in the intimal layer, resulting in bleeding between the intimal and medial layers of the arterial wall.
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?
Elevate the legs periodically for at least 15 to 20 minutes. Explanation: 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.
Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of:
Hemorrhage.
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?
In 3 to 5 days Explanation: 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)
Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending?
Increased abdominal and back pain
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?
Moderate to severe arterial insufficiency Explanation: 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.
Aortic dissection may be mistaken for which of the following disease processes?
Myocardial infarction (MI) Explanation: 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.
A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description?
Protamine sulfate Explanation: Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn't given orally.) Thrombin is a hemostatic agent used to control local bleeding. Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it's used to treat clients who are in shock.
A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important?
Recent pelvic surgery Explanation: The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes mellitus is a contributing factor associated with peripheral vascular disease.
Which of the following observations regarding ulcer formation on the patient's lower extremity indicates to the nurse that the ulcer is a result of venous insufficiency?
Size is large and superficial Explanation: Ulcerations are in the area of the medial or lateral malleolus (gaiter area) and are typically large, superficial, and highly exudative. Superficial venous insufficiency ulcers cause minimal pain. The base of a venous insufficiency ulcer shows beefy red to yellow fibrinous color.
A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions?
Stabilizing heart rate and blood pressure and easing anxiety
What should the nurse do to manage the persistent swelling in a patient with severe lymphangitis and lymphadenitis?
Teach the patient how to apply a graduated compression stocking. Explanation: In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the patient how to apply a graduated compression stocking. The nurse informs the physician if the temperature remains elevated. The nurse recommends elevating the area to reduce the swelling and provides warmth to promote comfort and to enhance circulation.
A patient is receiving enoxaparin (Lovenox) and warfarin (Coumadin) therapy for a venous thromboembolism (VTE). Which lab value indicates that anticoagulation is adequate and enoxaparin (Lovenox) can be discontinued?
The patient's international normalized ratio (INR) is 2.5. Explanation: 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 (ie, when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0)
The nurse is caring for a patient with venous insufficiency. What should the nurse assess the patient's lower extremities for?
Ulceration Explanation: 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.
What are the symptoms a nurse should assess for in a patient with lymphedema as a result of impaired nutrition to the tissue?
Ulcers and infection in the edematous area Explanation: In a patient with lymphedema, the tissue nutrition is impaired from 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 patients with lymphedema, and cyanosis is a bluish discoloration of the skin and mucous membranes.
For a client with thrombosis, what does the nurse do if pulses cannot be palpated?
Use Doppler ultrasound device. Explanation: A nurse uses a Doppler ultrasound device if pulses cannot be palpated for clients with thrombosis. Magnetic resonance imaging, radiography, and computed tomography scans are diagnostic tests to determine disorders of the endocrine, tumors, and so on.
The most common site of aneurysm formation is in the:
abdominal aorta, just below the renal arteries. Explanation: 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.
Which of the following are indications of a rupturing aortic aneurysm? Select all that apply.
• Constant, intense back pain • Decreasing blood pressure • Decreasing hematocrit Explanation: Indications of a rupturing abdominal aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit.
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?
"Walk to the point of pain, rest until the pain subsides, then resume ambulation." Explanation: 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 nurse suspects the presence of an abdominal aortic aneurysm. What assessment data would the nurse correlate with a diagnosis of abdominal aortic aneurysm?
-Lower abdominal pain -Low back pain -A pulsatile abdominal mass (most important)
A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following?
Arterial insufficiency Explanation: Characteristics of arterial insuffiency ulcers include location at the tips of the toes, extreme painfulness, and circular shape with pale to black ulcer bases. Ulcers caused by venous insufficiency will be irregular in shape, minimal pain if superficial (can be painful), and usually located around the ankles or the anterier tibial area.
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?
Atherosclerosis is the most common cause of peripheral arterial problems in the older adult.
A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection?
Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute. Explanation: 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.
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?
Contrast phlebography Explanation: 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.
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:
Decreases venous congestion. Explanation: 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.
A nurse is caring for a client who's had gastric bypass surgery. The physician encourages the client to increase mobility as soon as possible. The nurse notes edema to the right leg with skin color changes to the right lower extremity. The client reports pain at the incision site as 3 on a 0- to 10-point scale and pain to the right calf as 7 on a 0- to 10-point scale. The nurse reports the findings to the physician. She suspects that the client has:
Deep vein thrombosis. Explanation: Unilateral edema, skin color changes, and calf pain are all signs and symptoms of deep vein thrombosis, which can be a complication of postoperative immobility. An allergic reaction to the anesthesia would be generalized, rather than focused on the right lower extremity. The assessment data doesn't include any physiologic indicators of pain. Dehiscence would occur at the incision site in the abdominal area rather than at the calf.
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?
Epinephrine Explanation: 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 client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time?
Ineffective peripheral tissue perfusion related to venous congestion. Explanation: 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.
Which of the following are risk factors for venous disorders of the lower extremities?
Obesity Explanation: Careful assessment is invaluable in detecting early signs of venous disorders of the lower extremities. Patients with a history of varicose veins, hypercoagulation, neoplastic disease, cardiovascular disease, or recent major surgery or injury are at high risk. Other patients at high risk include those who are obese or older adults and women taking oral contraceptives.
When assessing a client with cellulitis of the right leg, which finding should the nurse expect to observe?
Red, swollen skin with inflammation spreading to surrounding tissues. Explanation: 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.
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?
Stop smoking. Explanation: 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. Antiembolytic 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.
The nurse teaches the patient with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes
a vasospasm. Explanation: Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities. Nicotine has stimulant effects. Nicotine does not suppress cough. Smoking irritates the bronchial tree, causing coughing. Nicotine does not cause diuresis.