Vascular Disorders

2. A 45-year-old patient with chronic arterial disease has a brachial systolic blood pressure (SBP) of 132 mm Hg and an ankle SBP of 102 mm Hg. The ankle-brachial index is ??? and indicates (mild/moderate/severe) arterial disease.

2. 102 ÷ 132 = 0.77; mild

13. A patient with a small AAA is not a good surgical candidate. What should the nurse teach the patient is the best way to prevent expansion of the lesion? a. Avoid strenuous physical exertion. b. Control hypertension with prescribed therapy. c. Comply with prescribed anticoagulant therapy. d. Maintain a low-calcium diet to prevent calcification of the vessel.

13. b. Increased systolic BP (SBP) continually puts pressure on the diseased area of the artery, promoting its expansion. Small aneurysms can be treated by decreasing BP, modifying atherosclerosis risk factors, and monitoring the size of the aneurysm. Anticoagulants are used during surgical treatment of aneurysms, but physical activity is not known to increase their size. Calcium intake is not related to calcification in arteries.

1. When obtaining a health history from a 72-year-old man with peripheral arterial disease (PAD) of the lower extremities, the nurse asks about a history of related conditions, including a. venous thrombosis. b. venous stasis ulcers. c. pulmonary embolism. d. coronary artery disease (CAD).

1. d. Regardless of the location, atherosclerosis is responsible for peripheral arterial disease (PAD) and is related to other cardiovascular disease and its risk factors, such as coronary artery disease (CAD) and carotid artery disease. Venous thrombosis, venous stasis ulcers, and pulmonary embolism are diseases of the veins and are not related to atherosclerosis.

10. Which aneurysm is uniform in shape and a circumferential dilation of the artery? a. False aneurysm b. Pseudoaneurysm c. Saccular aneurysm d. Fusiform aneurysm

10. d. The fusiform aneurysm is circumferential and relatively uniform in shape. The false aneurysm or pseudoaneurysm is not an aneurysm but a disruption of all the arterial wall layers with bleeding that is contained by surrounding anatomic structures. Saccular aneurysms are the pouchlike bulge of an artery.

11. A surgical repair is planned for a patient who has a 5.5-cm abdominal aortic aneurysm (AAA). On physical assessment of the patient, what should the nurse expect to find? a. Hoarseness and dysphagia b. Severe back pain with flank ecchymosis c. Presence of a bruit in the periumbilical area d. Weakness in the lower extremities progressing to paraplegia

11. c. Although most abdominal aortic aneurysms (AAAs) are asymptomatic, on physical examination a pulsatile mass in the periumbilical area slightly to the left of the midline may be detected and bruits may be audible with a stethoscope placed over the aneurysm. Hoarseness and dysphagia may occur with aneurysms of the ascending aorta and the aortic arch. Severe back pain with flank ecchymosis is usually present on rupture of an AAA and neurovascular loss in the lower extremities may occur from pressure of a thoracic aneurysm.

12. A thoracic aortic aneurysm is found when a patient has a routine chest x-ray. The nurse anticipates that additional diagnostic testing to determine the size and structure of the aneurysm will include which test? a. Angiography b. Ultrasonography c. Echocardiography d. CT scan

12. d. A CT scan is the most accurate test to determine the length and diameter of the aneurysm and whether a thrombus is present. The other tests may also be used, but the CT scan yields the most descriptive results.

14. During preoperative preparation of the patient scheduled for an AAA, why should the nurse establish baseline data for the patient? a. All physiologic processes will be changed postoperatively. b. The cause of the aneurysm is a systemic vascular disease. c. Surgery will be canceled if any physiologic function is not normal. d. BP and heart rate (HR) will be maintained well below baseline levels during the postoperative period.

14. b. Because atherosclerosis is a systemic disease, the patient with an AAA is likely to have cardiac, pulmonary, cerebral, or lower extremity vascular problems that should be noted and monitored throughout the perioperative period. Postoperatively, the BP is balanced: high enough to keep adequate flow through the artery to prevent thrombosis but low enough to prevent bleeding at the surgical site.

15. Which surgical therapy for an AAA is most likely to have the postoperative complication of renal injury? a. Open aneurysm repair (OAR) above the level of the renal arteries b. Excising only the weakened area of the artery and suturing the artery closed c. Bifurcated graft used in aneurysm repair when the AAA extends into the iliac arteries d. Endovascular graft procedure with an aortic graft inside the aneurysm via the femoral artery

15. a. With the aortic cross-clamping proximal and distal to the aneurysm, the open aneurysm repair (OAR) above the renal artery may cause kidney injury from lack of blood flow during the surgery. The saccular aneurysm may involve excising only the weakened area of the artery and suturing the artery closed, but this will not decrease renal blood flow. Renal blood flow will not be directly obstructed using the bifurcated graft or the minimally invasive endovascular aneurysm repair.

16. In preparation for an AAA repair surgery, what should the nurse include in patient teaching? a. Prepare the bowel on the night before surgery with laxatives or an enema. b. Use moisturizing soap to clean the skin three times the day before surgery. c. Eat a high-protein and high-carbohydrate breakfast to help with healing postoperatively. d. Take the prescribed oral antibiotic the morning of surgery before going to the operating room.

16. a. Usually aortic surgery patients will have a bowel preparation, skin cleansing with an antimicrobial agent on the day before surgery, nothing by mouth after midnight on the day of the surgery, and IV antibiotics immediately before the incision is made. Patients with a history of CVD will receive a β-adrenergic blocker preoperatively to reduce morbidity and mortality. Each surgeon's protocol may be different.

17. During the patient's acute postoperative period following repair of an AAA, the nurse should ensure that which goal is achieved? a. Hypothermia is maintained to decrease oxygen need. b. IV fluids are given to maintain urine output of 100 mL/hr. c. BP and all peripheral pulses are assessed at least every hour. d. The patient's BP is kept lower than baseline to prevent leaking at the incision line.

17. c. The BP and peripheral pulses are evaluated every hour in the acute postoperative period to ensure that BP is adequate to maintain graft patency and that extremities are being perfused. BP is kept within normal range. If BP is too low, thrombosis of the graft may occur; if it is too high, it may cause leaking or rupture at the suture line. Hypothermia is induced during surgery, but the patient is rewarmed as soon as surgery is over. Fluid replacement to maintain urine output at 100 mL/hr would increase the BP too much and only 30 mL/hr of urine is needed to show adequate renal perfusion.

18. Priority Decision: Following an ascending aortic aneurysm repair, what is an important finding that the nurse should report immediately to the HCP? a. Shallow respirations and poor coughing b. Decreased drainage from the chest tubes c. A change in level of consciousness and inability to speak d. Lower extremity pulses that are decreased from the preoperative baseline

18. c. During repair of an ascending aortic aneurysm, the blood supply to the carotid arteries may be interrupted, leading to neurologic complications manifested by a decreased level of consciousness (LOC) and altered pupil responses to light as well as changes in facial symmetry, speech, upper extremity movement, and hand grasp quality. The thorax is opened for ascending aortic surgery, and shallow breathing, poor cough, and decreasing chest drainage are expected. Lower limb pulses may normally be decreased or absent for a short time following surgery.

19. Which observation should indicate to the nurse the presence of the complication of graft thrombosis after an AAA repair? a. Cardiac dysrhythmias or chest pain b. Absent bowel sounds, abdominal distention, or diarrhea c. Increased temperature and increased white blood cell count d. Decreased pulses and cool, painful extremities below the level of repair

19. d. Decreased or absent pulses in conjunction with cool, painful extremities below the level of repair indicate graft thrombosis. Dysrhythmias or chest pain indicates myocardial ischemia. Absent bowel sounds, abdominal distention, diarrhea, or bloody stools indicate bowel infarction. Increased temperature and white blood cells (WBCs), surgical site inflammation, or drainage indicates graft infection.

20. Priority Decision: A patient who is postoperative following repair of an AAA has been receiving IV fluids at 125 mL/hr continuously for the last 12 hours. Urine output for the last 4 hours has been 60 mL, 42 mL, 28 mL, and 20 mL, respectively. What is the priority action that the nurse should take? a. Monitor for a couple more hours. b. Contact the HCP and report the decrease in urine output. c. Send blood for electrolytes, blood urea nitrogen (BUN), and creatinine. d. Decrease the rate of infusion to prevent blood leakage at the suture line.

20. b. The decreasing urine output is evidence that either the patient needs volume replacement or there is reduced renal blood flow. The HCP will want to be notified as soon as possible of this change in condition and will request results of daily blood urea nitrogen (BUN) and serum creatinine levels. The other options are incorrect.

21. Following discharge teaching with a male patient with an AAA repair, the nurse determines that further instruction is needed when the patient makes which statement? a. "I should avoid heavy lifting for 6 weeks." b. "I may have some sexual dysfunction because of the surgery." c. "I should maintain a low-fat and low-cholesterol diet to help keep the new graft open." d. "I will take the pulses in my legs and let the doctor know if they get too fast or too slow."

21. d. Patients are taught to palpate peripheral pulses to identify changes in their quality or strength, but the rate is not a significant factor in peripheral perfusion. The color and temperature of the extremities are important for patients to observe. The remaining statements are true.

22. During the nursing assessment of the patient with a type B aortic dissection, what should the nurse expect the patient to manifest? a. Altered level of consciousness (LOC) with dizziness and weak carotid pulses b. A cardiac murmur characteristic of aortic valve insufficiency c. Severe "ripping" back or abdominal pain with decreased urine output d. Severe hypertension and orthopnea and dyspnea of pulmonary edema

22. c. A Type B aortic dissection involves the distal descending aorta and is usually characterized by a sudden, severe, tearing pain in the back. As it progresses down the aorta, the kidneys, abdominal organs, and lower extremities may begin to show evidence of ischemia. Type A aortic dissections of the ascending aorta and aortic arch may affect the heart and circulation to the head, with the development of cerebral ischemia, murmurs, ventricular failure, and pulmonary edema.

23. A patient with a type A dissection of the arch of the aorta has a decreased LOC and weak carotid pulses. What should the nurse anticipate that initial treatment of the patient will include? a. Immediate surgery to replace the torn area with a graft b. Administration of anticoagulants to prevent embolization c. Administration of packed red blood cells (RBCs) to replace blood loss d. Giving antihypertensives to maintain a mean arterial pressure of 70 to 80 mmHg

23. a. Immediate surgery is indicated when complications (such as occlusion of the carotid arteries) occur. Otherwise, initial treatment for aortic dissection involves a period of lowering the BP and myocardial contractility to diminish the pulsatile forces in the aorta. Anticoagulants would prolong and intensify the bleeding. Blood is given only if the dissection ruptures.

24. The nurse evaluates that treatment for the patient with an uncomplicated aortic dissection is successful when what happens? a. Pain is relieved. b. Surgical repair is completed. c. BP is increased to normal range. d. Renal output is maintained at 30 mL/hr.

24. a. Relief of pain is a sign that the dissection has stabilized, and it may be treated conservatively for an extended time with drugs that lower the BP and decrease myocardial contractility. Surgery is usually indicated for Type A aortic dissection or if complications occur.

25. What are characteristics of PAD (select all that apply)? a. Pruritus b. Thickened, brittle nails c. Dull ache in calf or thigh d. Decreased peripheral pulses e. Pallor on elevation of the legs f. Ulcers over bony prominences on toes and feet

25. b, d, e, f. PAD is manifested as thick, brittle nails; decreased peripheral pulses; pallor when the legs are elevated; ulcers over bony prominences on the toes and feet; and paresthesia. The other options are characteristic of venous disease and paresthesia could occur with venous thromboembolism (VTE).

26. The patient is diagnosed with a superficial vein thrombosis (SVT). Which characteristic should the nurse know about SVT? a. Embolization to lungs may result in death. b. Clot may extend to deeper veins if untreated. c. Vein is tender to pressure and there is edema. d. Typically found in the iliac, inferior, or superior vena cava.

26. b. If left untreated, a superficial vein thrombosis (SVT) may extend to deeper veins and VTE may occur. VTE may embolize to the lungs and have tenderness to pressure and edema. SVTs usually occur in superficial leg veins and have tenderness, itchiness, redness, warmth, pain, inflammation, and induration along the course of the superficial vein.

27. Patient-Centered Care: The surgery area calls the transfer report for a 68-year-old, postmenopausal, female patient who smokes and takes hormone therapy. She is returning to the clinical unit after a lengthy hip replacement surgery. Which factors present in this patient increase her risk for developing venous thromboembolism (VTE) related to Virchow's triad (select all that apply)? a. Smoking b. IV therapy c. Dehydration d. Estrogen therapy e. Orthopedic surgery f. Prolonged immobilization

27. a, b, d, e, f. This patient is a smoker and on hormone therapy, both of which increase blood hypercoagulability. She will have an IV, and her fractured hip can cause VTE by damaging the venous endothelium. She is an older patient who has had an orthopedic surgery and may have experienced prolonged immobility postinjury and through her "lengthy hip replacement surgery," which contributes to venous stasis. These are representative of Virchow's triad in this patient. The other options are also related to Virchow's triad but not present in this patient via the transfer report.

28. The patient comes to the HCP office with pain, edema, and warm skin on her lower left leg. What test should the nurse expect to be ordered first? a. Duplex ultrasound b. Complete blood count (CBC) c. Magnetic resonance angiography d. Computed venography (phlebogram)

28. a. With manifestations of a VTE, the Duplex ultrasound is most widely used to diagnose VTE by identifying where a thrombus is found and its extent. D-dimer may also be drawn to determine if a VTE exists.

29. Collaboration: The nursing care area is very busy with new surgical patients. Which care could the registered nurse (RN) delegate to the unlicensed assistive personnel (UAP) for a patient with VTE? a. Assess the patient's use of herbs. b. Measure the patient for elastic compression stockings. c. Remind the patient to flex and extend the legs and feet every 2 hours. d. Teach the patient to call emergency response system with signs of pulmonary embolus.

29. c. The RN could delegate to the UAP the task to remind the patient to flex and extend the legs and feet every 2 hours while in bed. Measuring for elastic compression stockings may be delegated to the LPN. The RN must assess and teach the patient.

3. Priority Decision: Following teaching about medications for PAD, the nurse determines that more instruction is needed when the patient makes which statement? a. "I should take 1 aspirin a day to prevent clotting in my legs." b. "The lisinopril I use for my blood pressure may help me walk further without pain." c. "I will need to have frequent blood tests to evaluate the effect of the pentoxifylline I will be taking." d. "Cilostazol should help me increase my walking distance and speed and help prevent pain in my legs."

3. c. Pentoxifylline allows blood cells to pass through small vessels, but there are no blood tests related to it. Warfarin (Coumadin), which needs international normalized ration (INR) blood tests, is not recommended for prevention of cardiovascular disease (CVD) events in patients with PAD. All the other statements are correct in relation to treatment of PAD.

30. To help prevent embolization of a thrombus in a patient with acute VTE and severe edema and limb pain, what should the nurse teach the patient to do first? a. Dangle on the edge of the bed q2-3hr. b. Ambulate around the bed 3 to 4 times a day. c. Keep the affected leg elevated above the level of the heart. d. Maintain bed rest until edema is relieved and anticoagulation is established.

30. d. With acute VTE, prevention of emboli formation, decreased edema and pain can be achieved initially by bed rest and limiting movement of the involved extremity. Ambulation will be the next priority. Dangling the legs promotes venous stasis and further clot formation. Elevating the affected limb will promote venous return, but it does not prevent embolization.

31. Which indirect thrombin inhibitor is only given subcutaneously and does not need routine coagulation tests? a. Warfarin (Coumadin) b. Unfractionated heparin c. Hirudin derivatives (bivalirudin [Angiomax]) d. Low-molecular-weight heparin (enoxaparin [Lovenox])

31. d. Low-molecular-weight heparin (LMWH) (enoxaparin [Lovenox]) is only given subcutaneously and does not need routine coagulation testing. Unfractionated heparin is the only other indirect thrombin inhibitor option. It can be given subcutaneously or IV and therapeutic effects must be monitored with coagulation testing.

32. Which characteristics describe the anticoagulant warfarin (Coumadin) (select all that apply)? a. Vitamin K is the antidote b. Protamine sulfate is the antidote c. May be given orally or subcutaneously d. May be given intravenously or subcutaneously e. Monitor dosage using international normalized ratio (INR) f. Monitor dosage using activated partial thromboplastin time (aPTT)

32. a, e. Warfarin (Coumadin) is a vitamin K antagonist, so vitamin K is the antidote. It is monitored with the INR. It is only given orally. Protamine sulfate is the antidote for unfractionated heparin (UH) and LMWH. UH can be given subcutaneously or IV. It is monitored with activated partial thromboplastin time (aPTT). Hirudin derivatives are given IV or subcutaneously, do not have an antidote, and are monitored with aPTT. Argatroban, a synthetic thrombin inhibitor, is given only IV and is monitored with aPTT. Factor Xa inhibitor, fondaparinux (Arixtra), is given subcutaneously and does not need routine coagulation testing. Rivaroxaban (Xarelto), another factor Xa inhibitor, is given orally.

33. The patient with VTE is receiving therapy with heparin and asks the nurse whether the drug will dissolve the clot in her leg. What is the best response by the nurse? a. "This drug will break up and dissolve the clot so that circulation in the vein can be restored." b. "The purpose of the heparin is to prevent growth of the clot or formation of new clots where the circulation is slowed." c. "Heparin won't dissolve the clot, but it will inhibit the inflammation around the clot and delay the development of new clots." d. "The heparin will dilate the vein, preventing turbulence of blood flow around the clot that may cause it to break off and travel to the lungs."

33. b. Anticoagulant therapy with heparin or warfarin (Coumadin) does not dissolve clots but prevents propagation of the clot, development of new thrombi, and embolization. Clot lysis occurs naturally through the body's intrinsic fibrinolytic system or by the administration of thrombolytic agents.

34. A patient with VTE is to be discharged on long-term warfarin (Coumadin) therapy and is taught about prevention and continuing treatment of VTE. The nurse determines that discharge teaching for the patient has been effective when the patient makes which statement? a. "I should expect that Coumadin will cause my stools to be somewhat black." b. "I should avoid all dark green and leafy vegetables while I am taking Coumadin." c. "Massaging my legs several times a day will help increase my venous circulation." d. "Swimming is a good activity to include in my exercise program to increase my circulation."

34. d. Exercise programs for patients recovering from VTE should emphasize swimming, which is particularly beneficial because of the gentle, even pressure of the water. Coumadin will not blacken stools. If this occurs, it could be a sign of gastrointestinal bleeding. Dark green and leafy vegetables have high amounts of vitamin K and should not be increased during Coumadin therapy, but they do not need to be restricted. The legs must not be massaged because of the risk for dislodging any clots that may be present.

35. The nurse teaches the patient with any venous disorder that the best way to prevent venous stasis and increase venous return is to a. take short walks. b. sit with the legs elevated. c. frequently rotate the ankles. d. always wear elastic compression stockings.

35. a. During walking, the muscles of the legs continuously knead the veins, promoting movement of venous blood toward the heart. Walking is the best measure to prevent venous stasis and will be increased gradually. Elevating the legs will decrease edema. The other methods will help venous return, but they do not provide the benefit that ambulation does.

36. Number in sequence the processes that occur as venous stasis leads to varicose veins and to venous leg ulcers. a. Veins dilate b. Edema forms c. Ulceration occurs d. Venous pressure increases e. Capillary pressure increases f. Venous blood flow backs up g. Additional venous distention occurs h. Venous valves become incompetent i. Blood supply to local tissues decreases

36. a. 2; b. 7; c. 9; d. 1; e. 6; f. 4; g. 5; h. 3; i. 8 d. Venous pressure increases a. Veins dilate h. Venous valves become incompetent f. Venous blood flow backs up g. Additional venous distention occurs e. Capillary pressure increases b. Edema forms i. Blood supply to local tissues decreases c. Ulceration occurs

37. What is the most important measure in the treatment of venous leg ulcers? a. Elevation of the affected leg b. Application of topical antibiotics c. Graduated compression stockings d. Application of moist to dry dressings

37. c. Although leg elevation, moist dressings, and systemic antibiotics are useful in treatment of venous stasis ulcers, the most important factor is compression, which minimizes venous stasis, venous hypertension, and edema and prevents recurrence. Compression may be applied with various methods including stockings, elastic bandages or wraps, or a Velcro wrap, among others.

4. A patient with PAD has a nursing diagnosis of ineffective tissue perfusion. What should be included in the teaching plan for this patient (select all that apply)? a. Apply cold compresses when the legs become swollen. b. Wear protective footwear and avoid hot or cold extremes. c. Walk at least 30 minutes per day, at least 3 times per week. d. Use nicotine replacement therapy as a substitute for smoking. e. Inspect lower extremities for pulses, temperature, and any injury.

4. b, c, e. Protecting feet and legs from injury is important. Walking exercise increases oxygen extraction in the legs and improves skeletal muscle metabolism. The patient with PAD should walk at least 30 minutes a day, at least 3 times per week. Exercise should be stopped when pain occurs and resumed when the pain subsides. The lower extremities should be assessed at regular intervals for changes. Cold compresses and nicotine in all forms causes vasoconstriction and should be avoided.

5. When teaching the patient with PAD about modifying risk factors associated with the condition, what should the nurse emphasize? a. Amputation is the ultimate outcome if the patient does not alter lifestyle behaviors. b. Modifications will reduce the risk of other atherosclerotic conditions, such as stroke. c. Risk-reducing behaviors started after angioplasty can stop the progression of the disease. d. Maintenance of normal body weight is the most important factor in controlling arterial disease.

5. b. PAD occurs as a result of atherosclerosis and the risk factors are the same as for other diseases associated with atherosclerosis, such as CAD, cerebrovascular disease, and aneurysms. Major risk factors are tobacco use, hyperlipidemia, elevated C-reactive protein, diabetes, obesity, and uncontrolled hypertension. The risk for amputation is high in patients with severe occlusive disease, but this is not the best approach to encourage patients to make lifestyle modifications.

6. Priority Decision: During care of the patient following femoral bypass graft surgery, the nurse immediately notifies the health care provider (HCP) if the patient has a. fever and redness at the incision site. b. 2 + edema of the extremity and pain at the incision site. c. a loss of palpable pulses and numbness and tingling of the feet. d. increasing ankle-brachial indices and serous drainage from the incision.

6. c. Loss of palpable pulses, numbness and tingling of the extremity, extremity pallor, cyanosis, or cold are indications of occlusion of the bypass graft and need immediate medical attention. Pain, redness, and serous drainage at the incision site are expected postoperatively. Ankle brachial index measurements are not recommended because of increased risk for graft thrombosis, but this would decrease with occlusion.

8. Which conditions characterize critical limb ischemia (select all that apply)? a. Cold feet b. Arterial leg ulcers c. Venous leg ulcers d. Gangrene of the leg e. No palpable peripheral pulses f. Rest pain lasting more than 2 weeks

8. b, d, f. Arterial leg ulcers and/or gangrene of the leg caused by PAD and chronic ischemic rest pain lasting more than 2 weeks characterize critical limb ischemia. Optimal therapy is revascularization via bypass surgery.

9. What are characteristics of vasospastic disease (Raynaud's phenomenon) (select all that apply)? a. Predominant in young females b. May be associated with autoimmune disorders c. Precipitated by exposure to cold, caffeine, and tobacco d. Involves small cutaneous arteries of the fingers and toes e. Inflammation of small and medium sized arteries and veins f. Episodes involve white, blue, and red color changes of fingertips

9. a, b, c, d, f. Raynaud's phenomenon is predominant in young females and may be associated with autoimmune disorders (e.g., rheumatoid arthritis, scleroderma, systemic lupus erythematosus). Incidents occur with cold, emotional upsets, and caffeine or tobacco use because of vasoconstrictive effects. Small cutaneous arteries are involved and cause color changes of the fingertips or toes. When conservative management is ineffective, it may be treated with nifedipine (Procardia).

1. When assessing a patient with possible peripheral artery disease (PAD), the nurse obtains a brachial BP of 147/82 and an ankle pressure of 112/74. The nurse calculates the patient's ankle-brachial index (ABI) as ________ (round up to the nearest hundredth).

ANS: 0.76 The ABI is calculated by dividing the ankle systolic BP by the brachial systolic BP.

16. A 67-year-old patient is admitted to the hospital with a diagnosis of venous insufficiency. Which patient statement is most supportive of the diagnosis? a. "I can't get my shoes on at the end of the day." b. "I can't seem to ever 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 (PAD).

22. An 80-year-old patient with a history of an abdominal aortic aneurysm arrives at the emergency department (ED) with severe back pain and absent pedal pulses. Which actions should the nurse take first? a. Obtain the blood pressure. b. Obtain blood for laboratory testing. c. Assess for the presence of an abdominal bruit. d. Determine any family history of kidney disease.

ANS: A 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 also may be done, but they will not provide information that will determine what interventions are needed immediately for this patient.

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

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

24. 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 should the nurse take first? a. Notify the surgeon and anesthesiologist. b. Wrap both the legs in a warming blanket. c. Document the findings and recheck in 15 minutes. d. Compare findings to the preoperative assessment of the pulses.

ANS: A 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 should be reported to the physician immediately because this is an emergency situation. Because pulses are marked prior to surgery, the nurse would know whether pulses were present prior to surgery before notifying the health care providers about the absent pulses. 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.

9. After teaching a patient with newly diagnosed Raynaud's phenomenon about how to manage the condition, which action by the patient demonstrates that the teaching has been effective? a. The patient exercises indoors during the winter months. b. The patient places the 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.

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 sit in a chair for 90 minutes. b. The LPN/LVN assists the patient to walk 40 feet in the hallway. c. The LPN/LVN gives the ordered aspirin 160 mg after breakfast. d. The LPN/LVN places the patient in a 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.

17. Which nursing action should be included in the plan of care after endovascular repair of an abdominal aortic aneurysm? a. Record hourly chest tube drainage. b. Monitor fluid intake and urine output. c. Check the abdominal incision for any redness. d. Teach the reason for a prolonged recovery period.

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.

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. have to buy some loose clothes that do not bind across my legs or waist." b. use a heating pad on my feet at night to increase the circulation and warmth in my feet." c. change my position every hour and avoid long periods of sitting with my legs crossed." d. walk to the point of pain, rest, and walk again until the pain returns for at least 30 minutes 3 times a week."

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.

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. Begin oral intake. b. Obtain vital signs. c. Assess pedal pulses. d. Start discharge teaching.

ANS: B 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.

2. A patient has a 6-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining an admission history from the patient, it will be most important for the nurse to ask about a. low back pain. b. trouble 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 will be important to assess for in patients with abdominal aortic aneurysms.

11. The health care provider prescribes an infusion of heparin (Hep-Lock) 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 any IM medications to prevent localized bleeding. c. monitor posterior tibial and dorsalis pedis pulses with the Doppler. d. have vitamin K available in case reversal of the heparin is needed.

ANS: B IM injections are avoided in patients receiving anticoagulation. 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 some dyspnea d. Patient who needs teaching about the use of 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.

25. 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. Loose, bloody stools c. Hypoactive bowel sounds d. Abdominal pain with palpation

ANS: B Loose, bloody stools at this time may indicate intestinal ischemia or infarction, and should 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.

19. A 23-year-old 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.

13. The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) following 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 Coumadin." 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 Coumadin." d. "I will check with my health care provider before I begin any new medications."

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. When developing a teaching plan for a 76-year-old patient newly diagnosed with peripheral artery disease (PAD), which instructions should the nurse include? 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).

18. Which action by a nurse who is giving fondaparinux (Arixtra) to a patient with a lower leg venous thromboembolism (VTE) indicates that more education about the drug is needed? a. The nurse avoids rubbing the injection site after giving the drug. b. The nurse injects the drug into the abdominal subcutaneous tissue. c. The nurse ejects the air bubble in the syringe before giving the drug. d. The nurse fails to assess the partial thromboplastin time (PTT) before giving the drug.

ANS: C The air bubble is not ejected before giving fondaparinux to avoid loss of medication. The other actions by the nurse are appropriate.

7. The nurse performing an assessment with 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. a 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.

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 mostappropriate? a"Taking two blood thinners reduces the risk for another clot to form." b. "Lovenox will start to dissolve the clot, and Coumadin will prevent any more clots from forming." c. "Lovenox will work right away, but Coumadin takes several days to have an effect on preventing clots." 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: C 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. Furthermore, anticoagulants should not be described as blood thinners.

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 oxygen administration and notification of the health care provider. The other findings are typical of VTE.

31. 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 137/88 mm Hg d. 25 mL urine output over last hour

ANS: C The blood pressure is typically kept at less than 120 mm Hg systolic to minimize extension of the dissection. The nurse will need to notify the health care provider so that b-blockers or other antihypertensive medications can be prescribed. The other findings are typical with aortic dissection and should also be reported but do not require immediate action.

23. After receiving report, which patient admitted to the emergency department should the nurse assess first? a. 67-year-old who has a gangrenous left foot ulcer with a weak pedal pulse b. 58-year-old who is taking anticoagulants for atrial fibrillation and has black stools c. 50-year-old who is complaining of sudden "sharp" and "worst ever" upper back pain d. 39-year-old who has right calf tenderness, redness, and swelling after a long plane ride

ANS: C The patient's presentation is consistent with dissecting thoracic aneurysm, which will require rapid intervention. The other patients do not need urgent interventions.

1. When discussing risk factor modification for a 63-year-old patient who has a 5-cm abdominal aortic aneurysm, the nurse will focus discharge teaching on which patient risk factor? a. Male gender b. Turner syndrome c. Abdominal trauma history d. Uncontrolled hypertension

ANS: D All of the factors contribute to the patient's risk, but only hypertension can potentially be modified to decrease the patient's risk for further expansion of the aneurysm.

30. Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? 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 should be done by RNs.

35. The nurse reviews the admission orders shown in the accompanying figure for a patient newly diagnosed with peripheral artery disease. Which admission order should the nurse question? a. Use of treadmill for exercise b. Referral for dietary instruction c. Exercising to the point of discomfort d. Combined clopidogrel and omeprazole therapy

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

32. A patient is being evaluated for post-thrombotic 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. Check for presence of lipodermatosclerosis.

ANS: D Clinical signs of post-thrombotic 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.

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. "I get short of breath when I climb a lot of stairs." c. "My fingers hurt when I go outside in cold weather." d. "My legs cramp whenever I walk more than a block."

ANS: D 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.

3. Several hours after an open surgical repair of an abdominal aortic aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has been 40 mL. The nurse notifies the health care provider and anticipates an order for a(n) a. hemoglobin count. b. additional antibiotic. c. decrease in IV infusion rate. d. blood urea nitrogen (BUN) level.

ANS: D 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.

6. A patient at the clinic says, "I have always taken a 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. check 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. assess for the presence of the 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 (VTE).

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.