Vascular Quiz Ch 30
A patient comes to the walk-in clinic with complaints of pain in his foot following stepping on a roofing nail 4 days ago. The patient has a visible red streak running up his foot and ankle. What health problem should the nurse suspect? A) Cellulitis B) Local inflammation C) Elephantiasis D) Lymphangitis
Ans: D Feedback: Lymphangitis is an acute inflammation of the lymphatic channels. It arises most commonly from a focus of infection in an extremity. Usually, the infectious organism is hemolytic streptococcus. The characteristic red streaks that extend up the arm or the leg from an infected wound outline the course of the lymphatic vessels as they drain.
A client scheduled for a repair of an abdominal aortic aneurysm reports increased abdominal pain accompanied by new onset of intense back and flank pain. The priority action by the nurse would be to a. administer a prescribed analgesic. b. notify the physician immediately. c. reassess the client in another 5 minutes. d. take another set of vital signs.
B Ruptured abdominal aortic aneurysm presents with a triad of manifestations, including abdominal pain combined with intense back and flank pain and possible scrotal pain, a pulsating abdominal mass or a rigid abdomen from the hemorrhage, and shock. Surgery is the only intervention for clients with a ruptured abdominal aortic aneurysm.
A client with a diagnosed abdominal aortic aneurysm (AAA) develops lower back pain radiating to the groin. What is the nurse's interpretation of this information? a. The aneurysm clotted and is obstructing blood flow. b. The aneurysm is expanding and is preparing to rupture. c. The client feels the inflammation of the aneurysm. d. This is a normal sensation associated with an AAA.
B When an aneurysm is expanding or is preparing to rupture, the client may experience severe, sudden back or lower abdominal pain that can radiate to the groin, buttocks, or legs. The other explanations are not related to potential or actual rupture of the aneurysm.
A client with chronic peripheral arterial disease and claudication tells the nurse that burning pain often awakens him from sleep. What is the nurse's interpretation of this change? a. The client has inflow disease. b. The client has outflow disease. c. The client's disease is worsening. d. The client's disease is stable.
C Claudication is stage II of chronic peripheral arterial disease. In stage III, clients commonly experience pain while resting that awakens them at night. Clients with inflow disease experience discomfort in the lower back, buttocks, or thighs. Clients with outflow disease describe burning or cramping in the calves, ankles, feet, and toes associated with activity. Pain at rest is a sign that the disease is progressing and perfusion is altered, even with no activity.
A client is recovering after an embolectomy. What clinical manifestations consistent with compartment syndrome does the nurse watch for? a. Elevated temperature and excessive diaphoresis b. Loss of sensation and pallor near the surgical site c. Swelling, pain, and tension of the affected limb d. Increased pulse and warmth below the surgical site
C Compartment syndrome occurs when tissue pressure within a confined space becomes elevated and blood flow is restricted. This causes increased swelling, tenderness, and tension in the affected limb.
The nurse notes a venous ulcer on the client's left ankle. What additional assessment finding does the nurse expect in this client? a. Absence of hair on the left lower extremity b. Skin surrounding the ulcer mottled but blanchable c. Brownish discoloration of the lower extremity d. Cold and gray-blue lower extremity
C Venous ulcers are characterized by brown pigmentation of the skin of the lower extremity. Mottled skin, the presence of dependent rubor, and cyanosis are features of arterial ulcers.
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.
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.
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
A
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).
0.76 The ABI is calculated by dividing the ankle systolic BP by the brachial systolic BP.
The nurse is preparing a client with an aortic aneurysm for surgery. The nurse notes that the client's systolic blood pressure has increased by 30 mm Hg compared with the reading 1 hour ago. What is the nurse's best action? a. Measure abdominal girth. b. Auscultate the abdomen. c. Increase the IV infusion rate. d. Reassess the blood pressure.
A A sudden increase in blood pressure or hypertension can cause enlargement or rupture of the aneurysm, which would be correlated with an increase in abdominal girth. The other options are not indicated.
The health care provider has prescribed a client sodium warfarin (Coumadin) while he is still receiving intravenous heparin. Which is the nurse's best action? a. Administer both heparin and warfarin as prescribed. b. Turn off the heparin before administering the warfarin. c. Clarify the warfarin order with the nursing supervisor. d. Hold the warfarin dose until the heparin is discontinued.
A Although both heparin and warfarin are anticoagulants, they have different mechanisms of action and onsets of action. Because warfarin has such a slow onset, it must be started while the client is still receiving heparin. Once the warfarin is therapeutic, as evidenced by the international normalized ratio (INR), the client's heparin can be safely discontinued. Effects of heparin will be cleared from the client's bloodstream within a few hours.
The nurse reading the admission note for a client who has an arterial leg ulcer would anticipate that the ulcer will be characterized a. as being surrounded by atrophic tissue. b. as producing minimal pain. c. by a deep-red base. d. by irregular borders.
A Arterial leg ulcers are very painful, which distinguishes them from venous stasis ulcers. Arterial ulcers also have a sharp edge and a pale base and often are surrounded by atrophic tissue.
For a hospitalized client who experienced a sudden arterial occlusion yesterday, the nurse would review the chart for a history of a. atrial fibrillation. b. hypertension. c. iron deficiency anemia. d. oral contraceptive use.
A Emboli, the most common cause of sudden ischemia, usually are of cardiac origin during periods of atrial fibrillation.
The nurse is recovering a client with peripheral arterial disease who has just undergone percutaneous transluminal angioplasty. What complication does the nurse monitor for in the immediate postprocedure period? a. Bleeding b. Aspiration c. Hypertensive crisis d. Chest pain
A For this procedure, a catheter is advanced through a cannula inserted through the femoral artery. The nurse must monitor the client for bleeding at the puncture site.
A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? a. "I can use a heating pad on my legs if it's set on low." b. "I should not cross my legs when sitting or lying down." c. "I will go out and buy some warm, heavy socks to wear." d. "It's going to be really hard but I will stop smoking."
A Clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result. The other statements show good understanding of self-management.
The nurse is caring for four hypertensive clients. Which drug-laboratory value combination should the nurse report immediately to the health care provider? a. Furosemide (Lasix)/potassium: 2.1 mEq/L b. Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L c. Spironolactone (Aldactone)/potassium: 5.1 mEq/L d. Torsemide (Demadex)/sodium: 142 mEq/L
A Lasix is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and should be reported immediately.
A nurse suspects a client has an acute arterial occlusion. Early assessment findings that would confirm her suspicion include (Select all that apply) a. pain. b. pallor. c. paralysis. d. paresthesias e. pulselessness.
A, B, E Early signs are pain, pallor, and pulselessness. Paresthesias indicate advanced damage. Paralysis indicates irreversible damage.
The nurse is evaluating a patient's diagnosis of arterial insufficiency with reference to the adequacy of the patient's blood flow. On what physiological variables does adequate blood flow depend? Select all that apply. A) Efficiency of heart as a pump B) Adequacy of circulating blood volume C) Ratio of platelets to red blood cells D) Size of red blood cells E) Patency and responsiveness of the blood vessels
A, B, E Feedback: Adequate blood flow depends on the efficiency of the heart as a pump, the patency and responsiveness of the blood vessels, and the adequacy of circulating blood volume. Adequacy of blood flow does not primarily depend on the size of red cells or their ratio to the number of platelets.
The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers. The nurse's assessment should include which of the following components? Select all that apply. A) Location and type of pain B) Apical heart rate C) Bilateral comparison of peripheral pulses D) Comparison of temperature in the patient's legs E) Identification of mobility limitations
A, C, D, E Feedback: A careful nursing history and assessment are important. The extent and type of pain are carefully assessed, as are the appearance and temperature of the skin of both legs. The quality of all peripheral pulses is assessed, and the pulses in both legs are compared. Any limitation of mobility and activity that results from vascular insufficiency is identified. Not likely is there any direct indication for assessment of apical heart rate, although peripheral pulses must be assessed.
The nurse is reviewing a client's laboratory results. The nurse correlates elevations in which values as risk factors for atherosclerosis? (Select all that apply.) a. Total cholesterol, 280 mg/dL b. High-density cholesterol, 50 mg/dL c. Triglycerides, 200 mg/dL d. Serum albumin, 4 g/dL e. Low-density cholesterol, 160 mg/dL
A, C, E A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density cholesterol levels are all high, indicating higher risk for cardiovascular disease. High-density cholesterol is within the normal range for both males and females. Serum albumin is not assessed for atherosclerosis.
The nurse is caring for a patient who returned from the tropics a few weeks ago and who sought care with signs and symptoms of lymphedema. The nurse's plan of care should prioritize what nursing diagnosis? A) Risk for infection related to lymphedema B) Disturbed body image related to lymphedema C) Ineffective health maintenance related to lymphedema D) Risk for deficient fluid volume related to lymphedema
Ans: A Feedback: Lymphedema, which is caused by accumulation of lymph in the tissues, constitutes a significant risk for infection.
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."
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.
When a client with arterial insufficiency complains of being awakened at night by pain in the legs, the nurse would recommend that the client sleep a. after exercising for 10 to 15 minutes. b. in a recliner with feet dependent. c. propped up by several pillows. d. with legs covered by an extra blanket.
B Placing the legs in a dependent position provides increased gravitational blood supply.
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.
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.
What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.) a. Administering mild analgesics for pain b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises e. Teaching the client about surgical options
B, C, D The three E's of care for varicose veins include elastic compression hose, exercise, and elevation. Mild analgesics are not a nonpharmacologic measure. Teaching about surgical options is not a comfort measure.
A client who is receiving IV heparin has a PTT reported by the lab as 101. Appropriate actions by the nurse include (Select all that apply) a. continuing to monitor the heparin infusion. b. instituting safety precautions. c. notifying the physician. d. ordering another PTT in the morning. e. turning off the heparin IV.
B, C, E Bleeding can occur in the client receiving anticoagulant therapy. Heparin infusions are monitored with the PTT. Therapeutic levels are generally greater than 60, but at 1.5-2.5 times the baseline (normal is around 25-35). A PTT of 101 is a critical result and the nurse should (1) stop the heparin infusion, (2) notify the physician, and (3) place the client on bleeding precautions. A small injury to the client can cause bleeding. The client can also have spontaneous bleeding. The nurse should observe the client for bleeding, as evidenced by frank hemorrhage, changes in mental status, pink-tinged or frank blood in the urine, dark or tarry stools, and bleeding after brushing the teeth.
The nurse is preparing to administer warfarin (Coumadin) to a client with deep vein thrombophlebitis (DVT). Which laboratory value would most clearly indicate that the patient's warfarin is at therapeutic levels? A) Partial thromboplastin time (PTT) within normal reference range B) Prothrombin time (PT) eight to ten times the control C) International normalized ratio (INR) between 2 and 3 D) Hematocrit of 32%
C Feedback: The INR is most often used to determine if warfarin is at a therapeutic level; an INR of 2 to 3 is considered therapeutic. Warfarin is also considered to be at therapeutic levels when the client's PT is 1.5 to 2 times the control. Higher values indicate increased risk of bleeding and hemorrhage, whereas lower values indicate increased risk of blood clot formation. Heparin, not warfarin, prolongs PTT. Hematocrit does not provide information on the effectiveness of warfarin; however, a falling hematocrit in a client taking warfarin may be a sign of hemorrhage.
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."
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
A 73-year-old patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. The nurse should notify the health care provider and immediately 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.
D
Nurse is assessing pt with PAD. Which of the following should the nurse expect to find? A. edema around feet and ankles B. ulcerations around medial malleoli C. scaling eczema D. Pallor on elevation and ruber when dependent
D
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.
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).
The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning? a. Cholesterol: 126 mg/dL b. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL d. Triglycerides: 198 mg/dL
D Triglycerides in men should be below 160 mg/dL. The other values are appropriate for adult males.
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
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.
The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply.) a. Atherosclerosis b. Down syndrome c. Frequent heartburn d. History of hypertension e. History of smoking
A, D, E Atherosclerosis, hypertension, hyperlipidemia, and smoking are the most common related factors. Down syndrome and heartburn have no relation to aneurysm formation.
A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.) a. Administer pain medication. b. Assess distal pulses every 10 minutes. c. Have the client sign a surgical consent. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes.
ANS: B, D, E This client may have a ruptured/rupturing aneurysm. The nurse should notify the Rapid Response team and perform frequent client assessments. Giving pain medication will lower the client's blood pressure even further. The nurse cannot have the client sign a consent until the physician has explained the procedure.
The nurse is assessing a client who reports claudication after walking a distance of one block. The nurse notes a painful ulcer on the fourth toe of the client's right foot. What condition do these findings correlate with? a. Diabetic foot ulceration b. Peripheral arterial disease c. Peripheral venous disease d. Deep vein thrombosis
B Arterial disease is characterized by claudication after walking short distances. Ulcerations caused by peripheral arterial disease are painful and initially are located at the most distal points on the extremity.
The nurse assesses a client's legs. Which assessment finding indicates arterial insufficiency? a. Ankle discoloration and pitting edema b. Dependent mottling and absence of hair c. Pain with activity but not while resting d. Full veins present in dependent extremity
B Dependent mottling and absence of hair is an indication of arterial insufficiency. Pain may be present with activity and at rest. Edema and ankle discoloration would be indicative of venous insufficiency.
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.
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.
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.
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.
While assessing a patient the nurse notes that the patient's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best respond to this assessment finding? A) Assess the patient's use of over-the-counter dietary supplements. B) Implement interventions relevant to arterial narrowing. C) Encourage the patient to increase intake of foods high in vitamin K. D) Adjust the patient's activity level to accommodate decreased coronary output.
B Feedback: ABI is used to assess the degree of stenosis of peripheral arteries. An ABI of less than 1.0 indicates possible claudication of the peripheral arteries.
The nurse is providing care for a patient who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis? A) Numbness and tingling in the distal extremities B) Unequal peripheral pulses between extremities C) Visible clubbing of the fingers and toes D) Reddened extremities with muscle atrophy
B Feedback: PAD assessment may manifest as unequal pulses between extremities, with the affected leg cooler and paler than the unaffected leg
Important health promotion measures a nurse could teach a client in order to avoid another episode of DVT include (Select all that apply) a. avoiding prolonged sitting. b. elevating the legs when sitting. c. maintaining an ideal body weight. d. remaining hydrated.
A, C, D Virchow's triad describes the pathophysiologic conditions that have to exist in order to have a DVT. The components are venous stasis (caused by immobilization, prolonged travel, pregnancy, lack of use of the calf muscle pump, and heart disease, among others), hypercoagulability (caused by dehydration, blood dyscrasias, and oral contraceptives, among other things), and vascular injury (caused by fractures, trauma, dislocations, and chemical irritation, among other things). Two of the three factors must be present to form a DVT.
The nurse is caring for a patient with a large venous leg ulcer. What intervention should the nurse implement to promote healing and prevent infection? A) Provide a high-calorie, high-protein diet. B) Apply a clean occlusive dressing once daily and whenever soiled. C) Irrigate the wound with hydrogen peroxide once daily. D) Apply an antibiotic ointment on the surrounding skin with each dressing change.
Ans: A Feedback: Wound healing is highly dependent on adequate nutrition. The diet should be sufficiently high in calories and protein.
The triage nurse in the ED is assessing a patient who has presented with complaint of pain and swelling in her right lower leg. The patient's pain became much worse last night and appeared along with fever, chills, and sweating. The patient states, ìI hit my leg on the car door 4 or 5 days ago and it has been sore ever since.î The patient has a history of chronic venous insufficiency. What intervention should the nurse anticipate for this patient? A) Platelet transfusion to treat thrombocytopenia B) Warfarin to treat arterial insufficiency C) Antibiotics to treat cellulitis D) Heparin IV to treat VTE
Ans: C Feedback: Cellulitis is the most common infectious cause of limb swelling. The signs and symptoms include acute onset of swelling, localized redness, and pain; it is frequently associated with systemic signs of fever, chills, and sweating.
A nurse working in a long-term care facility is performing the admission assessment of a newly admitted, 85-year-old resident. During inspection of the resident's feet, the nurse notes that she appears to have early evidence of gangrene on one of her great toes. The nurse knows that gangrene in the elderly is often the first sign of what? A) Chronic venous insufficiency B) Raynaud's phenomenon C) VTE D) PAD
Ans: D Feedback: In elderly people, symptoms of PAD may be more pronounced than in younger people. In elderly patients who are inactive, gangrene may be the first sign of disease.
For a client admitted with a history of chronic arterial insufficiency, the nurse would anticipate that physical assessment will reveal a. rubor with elevation of feet. b. pallor when feet are dependent. c. diminished pedal pulses. d. warm, edematous skin.
C Objective data associated with arterial insufficiency include weak or absent peripheral pulses, dependent rubor, pallor with elevation, hypertrophied toenails, tissue atrophy, ulceration, and gangrene.
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
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 nurse is caring for a client who is receiving heparin therapy for a venous thromboembolism (VTE). The client's activated partial thromboplastin time (aPTT) before heparin therapy was 30 seconds. Which aPTT result indicates that anticoagulation is adequate at this time? a. 15 seconds b. 30 seconds c. 60 seconds d. 150 seconds
C Therapeutic aPTT values for clients receiving heparin should range from 1.5 to 2.5 times the control value.
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)
C may indicate PE
A nurse is reviewing the physiological factors that affect a patient's cardiovascular health and tissue oxygenation. What is the systemic arteriovenous oxygen difference? A) The average amount of oxygen removed by each organ in the body B) The amount of oxygen removed from the blood by the heart C) The amount of oxygen returning to the lungs via the pulmonary artery D) The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood
D
The nurse would inform a client diagnosed with a 2-cm aneurysm that such aneurysms usually require a. a resection. b. grafting. c. medications to raise BP. d. semi-annual ultrasound.
D Aneurysms less the 4 cm are usually not surgically repaired, but instead are assessed twice a year by ultrasound to assess changes. Antihypertensive medications are prescribed if indicated.
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
D Compression of the leg is essential to healing of venous stasis ulcers.
The nurse would inform a client with a venous ulcer that the client's ulcer will be treated with the traditional protocol of a. daily warm soaks and application of wet-to-moist saline dressings. b. enzymatic debridement and the area left open to air. c. local antibiotic ointment applied twice a day. d. pressure dressing left in place for 5 to 7 days.
D No topical treatment for venous ulcer is adequate without a compression dressing capable of sustaining pressure for at least 1 week.
