Ch. 38 MJ Flashcards Preview

Adult 1 Exam 1 > Ch. 38 MJ > Flashcards

Flashcards in Ch. 38 MJ Deck (30):
1

When discussing risk factor modification for a 60-year-old patient who has a 4-cm abdominal aortic aneurysm, the nurse will focus patient teaching on which of these patient risk factors?

a. Male gender

b. Marfan syndrome

c. Abdominal trauma history

d. Uncontrolled hypertension

d. Uncontrolled hypertension

2

patient has a 5-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining a nursing history from the patient, it will be most important to ask about

a. back or lumbar pain.

b. difficulty swallowing.

c. abdominal tenderness.

d. changes in bowel habits.

b. difficulty swallowing.

3

Several hours after an open surgical repair of an abdominal aortic aneurysm, the patient develops a urinary output of 20 mL/hr for 2 hours. The nurse notifies the health care provider and anticipates orders for

a. an additional antibiotic.

b. a white blood cell (WBC) count.

c. a decrease in IV infusion rate.

d. a blood urea nitrogen (BUN) level.

d. a blood urea nitrogen (BUN) level.

4

A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which medication category will the nurse plan to include when providing patient teaching about PAD management?

a. Statins

b. Vitamins

c. Thrombolytics

d. Anticoagulants

a. Statins

5

A patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. The nurse should notify the health care provider and

a. elevate the left leg on a pillow.

b. apply an elastic wrap to the leg.

c. assist the patient in gently exercising the leg.

d. keep the patient in bed in the supine position

d. keep the patient in bed in the supine position

6

A patient at the clinic says, “I have always taken an evening walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though.” The nurse should

a. attempt to palpate the dorsalis pedis and posterior tibial pulses.

b. check for the presence of tortuous veins bilaterally on the legs.

c. ask about any skin color changes that occur in response to cold.

d. assess for unilateral swelling, redness, and tenderness of either leg.

a. attempt to palpate the dorsalis pedis and posterior tibial pulses.

7

The nurse performing an assessment with a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the left great toe would expect to find

a. a positive Homans’ sign.

b. swollen, dry, scaly ankles.

c. prolonged capillary refill in all the toes.

d. a large amount of drainage from the ulcer.

c. prolonged capillary refill in all the toes.

8

In evaluating the patient outcomes following teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says,

a. “I will have to buy some loose clothing that does not bind across my legs or waist.”

b. “I will use a heating pad on my feet at night to increase the circulation and warmth in my feet.”

c. “I will walk to the point of pain, rest, and walk again until I develop pain for a half hour daily.”

d. “I will change my position every hour and avoid long periods of sitting with my legs down.”

b. “I will use a heating pad on my feet at night to increase the circulation and warmth in my feet.”

9

After teaching a patient with newly diagnosed Raynaud’s phenomenon about how to manage the condition, which behavior by the patient indicates that the teaching has been effective?

a. The patient avoids the use of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).

b. The patient exercises indoors during the winter months.

c. The patient places the hands in hot water when they turn pale.

d. The patient takes pseudoephedrine (Sudafed) for cold symptoms

b. The patient exercises indoors during the winter months.

10

The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with deep vein thrombosis. The best method for the nurse to use in elevating the patient’s feet is to

a. place the patient in the Trendelenburg position.

b. place two pillows under the calf of the affected leg.

c. elevate the bed at the knee and put pillows under the feet.

d. put one pillow under the thighs and two pillows under the lower legs.

d. put one pillow under the thighs and two pillows under the lower legs.

11

The health care provider prescribes an infusion of argatroban (Acova) and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). The nurse will plan to

a. avoid giving any IM medications to prevent localized bleeding.

b. discontinue the infusion for PTT values greater than 50 seconds.

c. monitor posterior tibial and dorsalis pedis pulses with the Doppler.

d. have vitamin K available in case reversal of the argatroban is needed

a. avoid giving any IM medications to prevent localized bleeding.

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 accurate?

a. “Administration of two anticoagulants reduces the risk for recurrent venous thrombosis.”

b. “Lovenox will start to dissolve the clot, and Coumadin will prevent any more clots from occurring.”

c. “The Lovenox will work immediately, but the Coumadin takes several days to have an effect on coagulation.”

d. “Because of the potential for a pulmonary embolism, it is important for you to have more than one anticoagulant.”

c. “The Lovenox will work immediately, but the Coumadin takes several days to have an effect on coagulation.”

13

The nurse has initiated discharge teaching for a patient who is to be maintained on warfarin (Coumadin) following hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says,

a. “I should reduce the amount of green, leafy vegetables that I eat.”

b. “I should wear a Medic Alert bracelet stating that I take Coumadin.”

c. “I will need to have blood tests routinely to monitor the effects of the Coumadin.”

d. “I will check with my health care provider before I begin or stop any medication.”

a. “I should reduce the amount of green, leafy vegetables that I eat.”

14

A 42-year-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Before discharging the patient, the nurse teaches the patient that

a. sitting at the work counter, rather than standing, is recommended.

b. compression stockings should be applied before getting out of bed.

c. exercises such as walking or jogging cause recurrence of varicosities.

d. taking one aspirin daily will help prevent clotting around venous valves.

b. compression stockings should be applied before getting out of bed.

15

Which topic will the nurse include in patient teaching for a patient with a venous stasis ulcer on the right lower leg?

a. Adequate carbohydrate intake

b. Prophylactic antibiotic therapy

c. Application of compression to the leg

d. Methods of keeping the wound area dry

c. Application of compression to the leg

16

A patient is admitted to the hospital with a diagnosis of chronic venous insufficiency. Which of these statements by the patient is most consistent with the diagnosis?

a. “I can’t get my shoes on at the end of the day.”

b. “I can never seem to get my feet warm enough.”

c. “I wake up during the night because my legs hurt.”

d. “I have burning leg pains after I walk three blocks.”

a. “I can’t get my shoes on at the end of the day.”

17

Which nursing action will 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 wound for redness or swelling.

d. Teach the reason for a prolonged rehabilitation process

b. Monitor fluid intake and urine output.

18

Which action by a nurse who is administering fondaparinux (Arixtra) to a patient with venous thromboembolism (VTE) indicates that more education about the medication is needed?

a. The nurse avoids rubbing the injection site after giving the medication.

b. The nurse injects the medication into the abdominal subcutaneous tissue.

c. The nurse fails to assess the partial thromboplastin time (PTT) before administration of the medication.

d. The nurse ejects the air bubble in the syringe before administering the Arixtra.

d. The nurse ejects the air bubble in the syringe before administering the Arixtra.

19

A patient tells the health care provider about experiencing cold, numb fingers when running during the winter and is diagnosed with Raynaud’s phenomenon. The nurse will anticipate teaching the patient about tests for

a. hypertension.

b. hyperlipidemia.

c. autoimmune disorders.

d. coronary artery disease.

c. autoimmune disorders.

20

While working in the outpatient clinic, the nurse notes that the medical record states that a patient has intermittent claudication. Which of these statements by the patient would be consistent with this information?

a. “When I stand too long, my feet start to swell up.”

b. “Sometimes I get tired 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.”

d. “My legs cramp whenever I walk more than a block.”

21

When developing a teaching plan for a patient newly diagnosed with peripheral artery disease (PAD), which information 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 on support hose early in the day before swelling occurs.”

b. “It is very important that you stop smoking cigarettes.”

22

A patient with a history of an abdominal aortic aneurysm is admitted to the emergency department (ED) with severe back pain and absent pedal pulses. Which action should the nurse take first?

a. Obtain the blood pressure.

b. Ask the patient about tobacco use.

c. Draw blood for ordered laboratory testing.

d. Assess for the presence of an abdominal bruit

a. Obtain the blood pressure.

23

Which of these patients admitted to the emergency department should the nurse assess first?

a. 62-year-old who has gangrenous ulcers on both feet

b. 50-year-old who is complaining of “tearing” chest pain

c. 45-year-old who is taking anticoagulants and has bloody stools

d. 36-year-old who has right calf tenderness, redness, and swelling

b. 50-year-old who is complaining of “tearing” chest pain

24

Immediately after repair of an abdominal aortic aneurysm, a patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which action should the nurse take first?

a. Wrap both the legs in warm blankets.

b. Notify the surgeon and anesthesiologist.

c. Document that the pulses are absent and recheck in 30 minutes.

d. Review the preoperative assessment form for data about the pulses.

d. Review the preoperative assessment form for data about the pulses.

25

When the nurse is caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important to communicate to the health care provider?

a. Absence of flatus

b. Loose, bloody stools

c. Hypotonic bowel sounds

d. Abdominal pain with palpation

b. Loose, bloody stools

26

When 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 take first?

a. Take the blood pressure and pulse rate.

b. Check for the presence of pedal pulses.

c. Assess the appearance of any ischemic ulcers.

d. Start discharge teaching about antiplatelet drugs

a. Take the blood pressure and pulse rate.

27

A patient who has had a femoral-popliteal bypass graft to the right leg is being cared for on the surgical unit. Which action by an LPN/LVN caring for the patient requires the RN to intervene?

a. The LPN/LVN places the patient in a Fowler’s position for meals.

b. The LPN/LVN has the patient sit in a bedside chair for 90 minutes.

c. The LPN/LVN assists the patient to ambulate 40 feet in the hallway.

d. The LPN/LVN administers the ordered aspirin 160 mg after breakfast.

b. The LPN/LVN has the patient sit in a bedside chair for 90 minutes.

28

A 46-year-old is diagnosed with thromboangiitis obliterans (Buerger’s disease). When the nurse is planning expected outcomes for the patient, which outcome has the highest priority for this patient?

a. Cessation of smoking

b. Control of serum lipid levels

c. Maintenance of appropriate weight

d. Demonstration of meticulous foot care

a. Cessation of smoking

29

Which information about a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse?

a. Complaint of left calf pain

b. New onset shortness of breath

c. Red skin color of left lower leg

d. Temperature of 100.4° F (38° C)

b. New onset shortness of breath

30

Which nursing action in the care plan for a patient who had an open repair of an abdominal aortic aneurysm 3 days previously is appropriate for the nurse to delegate to experienced nursing assistive personnel (NAP)?

a. Check the lower extremity strength and movement.

b. Monitor the quality and presence of the pedal pulses.

c. Teach the patient the signs of possible wound infection.

d. Help the patient to use a pillow to splint while coughing


d. Help the patient to use a pillow to splint while coughing