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Flashcards in Peripheral Vascular Disorders Deck (121)
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1

The 66-year-old male client has his blood pressure (BP) checked at a health fair. The B/P is 168/98. Which action should the nurse implement first? 1. Recommend that the client have his blood pressure checked in one (1) month. 2. Instruct the client to see his health-care provider as soon as possible. 3. Discuss the importance of eating a low-salt, low-fat, low-cholesterol diet. 4. Explain that this B/P is within the normal range for an elderly person.

2. The diastolic blood pressure should be less than 85 according to the American Heart Association; therefore, this client should see the health-care provider.

2

The nurse is teaching the client recently diagnosed with essential hypertension. Which instruction should the nurse provide when discussing exercise? 1. Walk at least 30 minutes a day on flat surfaces. 2. Perform light weight lifting three (3) times a week. 3. Recommend high-level aerobics daily. 4. Encourage the client to swim laps once a week.

1. Walking 30 to 45 minutes a day will help in reducing blood pressure, weight, and stress and will increase a feeling of overall wellbeing.

3

The health-care provider prescribes an ACE inhibitor for the client diagnosed with essential hypertension. Which statement is the most appropriate rationale for administering this medication? 1. ACE inhibitors prevent the beta-receptor stimulation in the heart. 2. This medication blocks the alpha receptors in the vascular smooth muscle. 3. ACE inhibitors prevent vasoconstriction and sodium and water retention. 4. ACE inhibitors decrease blood pressure by relaxing vascular smooth muscle.

3. Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of angiotensin I to angiotensin II, and this, in turn, prevents vasoconstriction and sodium and water retention.

4

The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which intervention should the nurse implement? 1. Notify the health-care provider if the potassium level is 3.8 mEq. 2. Question administering the medication if the blood pressure is 90/60 mmHg. 3. Do not administer the medication if the client’s radial pulse is 100. 4. Monitor the client’s blood pressure while he or she is lying, standing, and sitting.

2. The nurse should question administering the beta blocker if the B/P is low because this medication will cause the blood pressure to drop even lower, leading to hypotension.

5

The male client diagnosed with essential hypertension has been prescribed an alphaadrenergic blocker. Which intervention should the nurse discuss with the client? 1. Eat at least one (1) banana a day to help increase the potassium level. 2. Explain that impotence is an expected side effect of the medication. 3. Take the medication on an empty stomach to increase absorption. 4. Change position slowly when going from lying to sitting position.

4. Orthostatic hypotension may occur when the blood pressure is decreasing and may lead to dizziness and light-headedness so the client should change position slowly.

6

The nurse just received the A.M. shift report. Which client should the nurse assess first? 1. The client diagnosed with coronary artery disease who has a BP of 170/100. 2. The client diagnosed with deep vein thrombosis who is complaining of chest pain. 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 98%. 4. The client diagnosed with ulcerative colitis who has nonbloody diarrhea.

2. The chest pain could be a pulmonary embolus secondary to deep vein thrombosis and requires immediate intervention by the nurse

7

The client diagnosed with essential hypertension asks the nurse, “Why do I have high blood pressure?” Which response by the nurse would be most appropriate? 1. “You probably have some type of kidney disease that causes the high BP.” 2. “More than likely you have had a diet high in salt, fat, and cholesterol.” 3. “There is no specific cause for hypertension, but there are many known risk factors.” 4. “You are concerned that you have high blood pressure. Let’s sit down and talk.”

3. There is no known cause for essential hypertension, but many factors, both modifiable (obesity, smoking, diet) and nonmodifiable (family history, age, gender) are risk factors for essential hypertension.

8

The nurse is teaching the Dietary Approaches to Stop Hypertension (DASH) diet to a client diagnosed with essential hypertension. Which statement indicates that the client understands the client teaching concerning the DASH diet? 1. “I should eat at least four (4) to five (5) servings of vegetables a day.” 2. “I should eat meat that has a lot of white streaks in it.” 3. “I should drink no more than two (2) glasses of whole milk a day.” 4. “I should decrease my grain intake to no more than twice a week.”

1. The DASH diet has proved beneficial in lowering blood pressure. It recommends eating a diet high in vegetables and fruits.

9

The client diagnosed with essential hypertension is taking a loop diuretic daily. Which assessment data would require immediate intervention by the nurse? 1. The telemetry reads normal sinus rhythm. 2. The client has a weight gain of 2 kg within 1–2 days. 3. The client’s blood pressure is 148/92. 4. The client’s serum potassium level is 4.5 mEq.

2. Rapid weight gain—for example, 2 kg in 1–2 days—indicates that the loop diuretic is not working effectively; 2 kg equals 4.4 lbs; 1 L of fluid weighs l kg.

10

The client diagnosed with essential hypertension asks the nurse, “I don’t know why the doctor is worried about my blood pressure. I feel just great.” Which statement by the nurse would be the most appropriate response? 1. “Damage can be occurring to your heart and kidneys even if you feel great.” 2. “Unless you have a headache your blood pressure is probably within normal limits.” 3. “When is the last time you saw your doctor? Does he know you are feeling great?” 4. “Your blood pressure reflects how well your heart is working.”

10. 1. Even if the client feels great, the blood pressure can be elevated, causing damage to the heart, kidney, and blood vessels.

11

The intensive care department nurse is calculating the total intake for a client diagnosed with hypertensive crisis. The client has received 880 mL of D5W, IVPB of 100 mL of 0.9% NS, 8 ounces of water, 4 ounces of milk, and 6 ounces of chicken broth. The client has had a urinary output of 1480 mL. What is the total intake for this client?_______

1520 mL total intake. The urinary output is not used in this calculation. The nurse must add up both intravenous fluids and oral fluids to obtain the total intake for this client; 880 100 980 IV fluids; (1 ounce 30 mL) 8 ounces 30 mL 240 mL, 4 ounces 30 mL 120 mL, 6 ounces 30 mL 180 mL; 240 120 180 540 oral fluids. Total intake is 980 540 1520.

12

The nurse is teaching a class on arterial essential hypertension. Which modifiable risk factors would the nurse include when preparing this presentation? 1. Include information on retinopathy and nephropathy. 2. Discuss sedentary lifestyle and smoking cessation. 3. Include discussions on family history and gender. 4. Provide information on a low-fiber and high-salt diet.

2. Sedentary lifestyle is discouraged in clients with hypertension, and daily isotonic exercises are recommended. Smoking increases the atherosclerotic process in vessels; causes vasoconstriction of vessels; and adheres to hemoglobin, decreasing oxygen levels.

13

The client comes to the clinic complaining of muscle cramping and pain in both legs when walking for short periods of time. Which medical term would the nurse document in the client’s record? 1. Peripheral vascular disease (PVD). 2. Intermittent claudication. 3. Deep vein thrombosis (DVT). 4. Dependent rubor.

2. This is the classic symptom of arterial occlusive disease.

14

Which instruction should be included when a client diagnosed with peripheral arterial disease is being discharged? 1. Encourage the client to use a heating pad on lower extremities. 2. Demonstrate to the client the correct way to apply elastic support hose. 3. Instruct the client to walk daily for at least 30 minutes. 4. Tell the client to check both feet for red areas at least once a week.

3. Walking promotes the development of collateral circulation to ischemic tissue and slows the process of atherosclerosis.

15

The nurse is teaching the client diagnosed with arterial occlusive disease. Which interventions should the nurse include in the teaching? Select all that apply. 1. Wash legs and feet daily in warm water. 2. Apply moisturizing cream to feet. 3. Buy shoes in the morning hours only. 4. Do not wear any type of knee stocking. 5. Wear clean white cotton socks.

1. Cold water causes vasoconstriction and hot water may burn the client’s feet; therefore, warm tepid water should be recommended. 2. Moisturizing prevents drying of the feet. 4. This will further decrease circulation to the legs. 5. Colored socks have dye and dirty socks may cause foot irritation that may lead to breaks in the skin.

16

Which assessment data would warrant immediate intervention in the client diagnosed with arterial occlusive disease? 1. The client has 2 pedal pulses. 2. The client is able to move the toes. 3. The client has numbness and tingling. 4. The client’s feet are red when standing.

3. Numbness and tingling are paresthesia, which is a sign of a severely decreased blood supply to the lower extremities.

17

Which client problem would be priority in a client diagnosed with arterial occlusive disease who is admitted to the hospital with a foot ulcer? 1. Impaired skin integrity. 2. Activity intolerance. 3. Ineffective health maintenance. 4. Risk for peripheral neuropathy.

17. 1. The client has a foot ulcer, therefore the protective lining of the body—the skin— has been impaired.

18

The client diagnosed with arterial occlusive disease is one (1) day post-operative right femoral popliteal bypass. Which intervention should the nurse implement? 1. Keep the right leg in the dependent position. 2. Apply sequential compression devices to lower extremities. 3. Monitor the client’s pedal pulses every shift. 4. Assess the client’s leg dressing every four (4) hours.

4. The leg dressing needs to be assessed for hemorrhaging or signs of infection.

19

The nurse is unable to assess a pedal pulse in the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement first? 1. Complete a neurovascular assessment. 2. Use the Doppler device. 3. Instruct the client to hang the feet off the side of the bed. 4. Wrap the legs in a blanket.

1. An absent pulse is not uncommon in a client diagnosed with arterial occlusive disease, but the nurse must ensure that the feet can be moved and are warm, which indicates adequate blood supply to the feet.

20

The wife of a client with arterial occlusive disease tells the nurse, “My husband says he is having rest pain. What does that mean?” Which statement by the nurse would be most appropriate? 1. “It describes the type of pain he has when he stops walking.” 2. “His legs are deprived of oxygen during periods of inactivity.” 3. “You are concerned that your husband is having rest pain.” 4. “This term is used to support that his condition is getting better.”

2. Rest pain indicates a worsening of the arterial occlusive disease; the muscles of the legs are not getting enough oxygen when the client is resting to prevent muscle ischemia.

21

The nurse is assessing the client diagnosed with long-term arterial occlusive disease. Which assessment data support the diagnosis? 1. Hairless skin on the legs. 2. Brittle, flaky toe nails. 3. Petechiae on the soles of feet. 4. Nonpitting ankle edema.

1. The decreased oxygen over time causes the loss of hair on top of feet and ascends both legs.

22

The health-care provider ordered a femoral angiogram for the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement? 1. Explain that this procedure will be done at the bedside. 2. Discuss with the client that he or she will be on bed rest with bathroom privileges. 3. Inform the client that no intravenous access will be needed. 4. Inform the client that fluids will be increased after the procedure.

4. Fluids will help flush the contrast dye out of the body and help prevent kidney damage.

23

Which medication should the nurse expect the health-care provider to order for a client diagnosed with arterial occlusive disease? 1. An anticoagulant medication. 2. An antihypertensive medication. 3. An antiplatelet medication. 4. A muscle relaxant.

3. Anti-platelet medications inhibit platelet aggregations in the arterial blood, such as aspirin or clopidogrel (Plavix).

24

The nurse and an unlicensed nursing assistant are caring for a 64-year-old client who is four (4) hours post-operative bilateral femoral–popliteal bypass surgery. Which nursing task should be delegated to the unlicensed nursing assistant? 1. Monitor the continuous passive motion machine. 2. Assist the client to the bedside commode. 3. Feed the client the evening meal. 4. Elevate the foot of the client’s bed.

4. After the surgery, the client’s legs will be elevated to help decrease edema. The surgery has corrected the decreased blood supply to the lower legs.

25

The nurse is teaching a class on coronary artery disease. Which modifiable risk factors should the nurse discuss when teaching about atherosclerosis? 1. Stress. 2. Age. 3. Gender. 4. Family history.

1. A modifiable risk factor is a risk factor that can possibly be altered by modifying or changing behavior, such as developing new ways to deal with stress.

26

The client asks the nurse, “My doctor just told me that atherosclerosis is why my legs hurt when I walk. What does that mean?” Which response by the nurse would be the best response? 1. “The muscle fibers and endothelial lining of your arteries have become thickened.” 2. “The next time you see your HCP ask what atherosclerosis means.” 3. “The valves in the veins of your legs are incompetent so your legs hurt.” 4. “You have a hardening of your arteries that decreases the oxygen to your legs.”

4. This response explains in plain terms why the client’s legs hurt from atherosclerosis.

27

The client diagnosed with peripheral vascular disease is overweight, has smoked two (2) packs of cigarettes a day for 20 years, and sits behind a desk all day. What is the strongest factor in the development of atherosclerotic lesions? 1. Being overweight. 2. Sedentary lifestyle. 3. High-fat, high-cholesterol diet. 4. Smoking cigarettes.

4. Tobacco use is the strongest factor in the development of atherosclerotic lesions. Nicotine decreases blood flow to the extremities and increases heart rate and blood pressure. It also increases the risk of clot formation by increasing the aggregation of platelets.

28

The client tells the nurse that his cholesterol level is 240 mg/dL. Which action should the nurse implement? 1. Praise the client for having a normal cholesterol level. 2. Explain that the client needs to lower the cholesterol level. 3. Discuss dietary changes that could help increase the level. 4. Allow the client to ventilate feelings about the blood test result.

2. The client needs to be taught ways to lower the cholesterol level.

29

The nurse is discussing the pathophysiology of atherosclerosis with a client who has a normal high-density lipoprotein (HDL) level. Which information should the nurse discuss with the client concerning HDL? 1. A normal HDL is good because it has a protective action in the body. 2. HDL lipoprotein level measures the free fatty acids and glycerol in the blood. 3. HDLs are the primary transporters of cholesterol into the cell. 4. The client needs to decrease the amount of cholesterol and fat in the diet.

1. A normal HDL level is good because HDL transports cholesterol away from the tissues and cells of the arterial wall to the liver for excretion. This helps decrease the development of atherosclerosis.

30

Which assessment data would cause the nurse to suspect the client has atherosclerosis? 1. Change in bowel movements. 2. Complaints of a headache. 3. Intermittent claudication. 4. Venous stasis ulcers.

3. Intermittent claudication is a sign of generalized atherosclerosis and is a marker of atherosclerosis.

31

The nurse is teaching a class on atherosclerosis. Which statement describes the scientific rationale as to why diabetes is a risk factor for developing atherosclerosis? 1. Glucose combines with carbon monoxide, instead of with oxygen, and this leads to oxygen deprivation of tissues. 2. Diabetes stimulates the sympathetic nervous system, resulting in peripheral constriction that increases the development of atherosclerosis. 3. Diabetes speeds the atherosclerotic process by thickening the basement membrane of both large and small vessels. 4. The increased glucose combines with the hemoglobin, which causes deposits of plaque in the lining of the vessels.

3. This is the scientific rationale why diabetes mellitus is a modifiable risk factor for atherosclerosis.

32

The nurse is discussing the importance of exercising with a client who is diagnosed with CAD. Which statement best describes the scientific rationale for encouraging 30 minutes of walking daily to help prevent complications of atherosclerosis? 1. Exercise promotes the development of collateral circulation. 2. Isometric exercises help develop the client’s muscle mass. 3. Daily exercise helps prevent plaque from developing in the vessel. 4. Isotonic exercises promote the transport of glucose into the cell.

1. Collateral circulation is the development of blood supply around narrowed arteries; it helps prevent complications of atherosclerosis, including myocardial infarction, cerebrovascular accidents, and peripheral vascular disease. Exercise promotes the development of collateral circulation.

33

The HCP prescribes an HMG-COA reductase inhibitor (statin) medication to a client with CAD. Which should the nurse teach the client about this medication? 1. Take this medication on an empty stomach. 2. This medication should be taken in the evening. 3. Do not be concerned if muscle pain occurs. 4. Check your cholesterol level daily.

2. Statin medications should be taken in the evening for best results because the enzyme that destroys cholesterol works best in the evening and the medication enhances this process.

34

The nurse knows the client understands the teaching concerning a low-fat, lowcholesterol diet when the client selects which meal? 1. Fried fish, garlic mashed potatoes, and iced tea. 2. Ham and cheese on white bread and whole milk. 3. Baked chicken, baked potato, and skim milk. 4. A hamburger, French fries, and carbonated beverage.

3. Baked, broiled, or grilled meats are recommended; a plain baked potato is appropriate; and skim milk is low in fat—so this meal is appropriate for a low-fat, lowcholesterol diet.

35

Which interventions should the nurse discuss with the client diagnosed with atherosclerosis? Select all that apply. 1. Include significant other in the discussion. 2. Stop smoking or using any type of tobacco products. 3. Maintain a sedentary lifestyle as much as possible. 4. Avoid stressful situations. 5. Daily isometric exercises are important.

1. Adherence to lifestyle modifications is enhanced when the client receives support from significant others. 2. Tobacco use is the most significant modifiable risk factor that contributes to the development of atherosclerosis.

36

The nurse is caring for clients on a telemetry floor. Which nursing task would be most appropriate to delegate to an unlicensed nursing assistant? 1. Teach the client how to perform a Glucometer check. 2. Assist feeding the client diagnosed with congestive heart failure. 3. Check the cholesterol level for the client diagnosed with atherosclerosis. 4. Assist the nurse to check the unit of blood at the client’s bedside.

2. The nursing assistant can feed a client.

37

Which assessment data would support the diagnosis of abdominal aortic aneurysm (AAA)? 1. Shortness of breath. 2. Abdominal bruit. 3. Ripping abdominal pain. 4. Decreased urinary output.

2. A systolic bruit over the abdomen is a diagnostic indication of an AAA.

38

Which medical treatment would be prescribed for the client with an AAA less than 3 cm? 1. Ultrasound every six (6) months. 2. Intravenous pyelogram yearly. 3. Assessment of abdominal girth monthly. 4. Repair of abdominal aortic aneurysm.

1. When the aneurysm is small (5–6 cm) an abdominal sonogram will be done every six (6) months until the aneurysm reaches a size at which surgery to prevent rupture is of more benefit than possible complications of an abdominal aortic aneurysm repair.

39

Which client would be most likely to develop an abdominal aortic aneurysm? 1. A 45-year-old female with a history of osteoporosis. 2. An 80-year-old female with congestive heart failure. 3. A 69-year-old male with peripheral vascular disease. 4. A 30-year-old male with a genetic predisposition to AAA.

3. The most common cause of AAA is atherosclerosis (which is the cause of peripheral vascular disease); it occurs in men four (4) times more often than women and primarily in Caucasians.

40

The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment? 1. “I have stomach pain every time I eat a big, heavy meal.” 2. “I don’t have any abdominal pain or any type of problems.” 3. “I have periodic episodes of constipation and then diarrhea.” 4. “I belch a lot, especially when I lay down after eating.”

2. Only about two-fifths of clients with AAA have symptoms; the remainder are asymptomatic.

41

The client is admitted for surgical repair of an 8-cm abdominal aortic aneurysm. Which sign/symptom would make the nurse suspect the client has an expanding AAA? 1. Complaints of low back pain. 2. Weakened radial pulses. 3. Decreased urine output. 4. Increased abdominal girth.

1. Low back pain is present because of the pressure of the aneurysm on the lumbar nerves; this is a serious symptom, usually indicating that the aneurysm is expanding rapidly and about to rupture.

42

The client is one (1) day post-operative abdominal aortic aneurysm repair. Which information from the unlicensed nursing assistant would require immediate intervention from the nurse? 1. The client refuses to turn from the back to the side. 2. The client’s urinary output is 90 mL in six (6) hours. 3. The client wants to sit on the side of the bed. 4. The client’s vital signs are T 98, P 90, R 18, and BP 130/70.

2. The client must have 30 mL urinary output every hour. Clients who are post-operative AAA are at high risk for renal failure because of the anatomical location of the AAA near the renal arteries.

43

The client had an abdominal aortic aneurysm repair two (2) days ago. Which intervention should the nurse implement first? 1. Assess the client’s bowel sounds. 2. Administer an IV prophylactic antibiotic. 3. Encourage the client to splint the incision. 4. Ambulate the client in the room with assistance.

1. Assessment is the first part of the nursing process and is the first intervention the nurse should implement.

44

Which health-care provider’s order should the nurse question in a client diagnosed with an expanding abdominal aortic aneurysm who is scheduled for surgery in the morning? 1. Type and cross-match for two (2) units of blood. 2. Tap water enema until clear fecal return. 3. Bed rest with bathroom privileges. 4. Keep NPO after midnight.

2. Increased pressure in the abdomen secondary to a tap water enema could cause the AAA to rupture.

45

The client is diagnosed with a small abdominal aortic aneurysm. Which interventions should be included in the discharge teaching? Select all that apply. 1. Tell the client to exercise three (3) times a week for 30 minutes. 2. Encourage the client to eat a low-fat, low-cholesterol diet. 3. Instruct the client to decrease tobacco use. 4. Discuss with the client the importance of losing weight. 5. Teach the client to wear a truss at all times.

1. The most common cause of AAA is atherosclerosis, so teaching should address this area. 2. A low-fat, low-cholesterol diet will help decrease development of atherosclerosis. 4. Losing weight will help decrease the pressure on the AAA and will help address decreasing the cholesterol level.

46

Which assessment data would require immediate intervention by the nurse for the client who is six (6) hours post-operative abdominal aortic aneurysm repair? 1. Absent bilateral pedal pulses. 2. Complaints of pain at the site of the incision. 3. Distended, tender abdomen. 4. An elevated temperature of 100F.

1. Any neurovascular abnormality in the client’s lower extremities indicates the graft is occluded or possibly bleeding and requires immediate intervention by the nurse.

47

The nurse is discussing discharge teaching with the client who is three (3) days postoperative abdominal aortic aneurysm repair. Which discharge instructions should the nurse include when teaching the client? 1. Notify HCP of any redness or irritation of incision. 2. Do not lift anything more than 20 pounds. 3. Inform client that there may be pain not relieved with pain medication. 4. Stress the importance of having daily bowel movements.

1. Redness or irritation of the incision indicates infection and should be reported immediately to the HCP.

48

The nurse is discharging a client diagnosed with DVT from the hospital. Which discharge instructions should be provided to the client? 1. Have the PTT levels checked weekly until therapeutic range is achieved. 2. Staying at home is best, but if traveling, airplanes are better than automobiles. 3. Avoid green leafy vegetables and notify the HCP of red or brown urine. 4. Wear knee stockings with an elastic band around the top.

3. Green leafy vegetables contain vitamin K, which is the antidote for warfarin. These foods will interfere with the action of warfarin. Red or brown urine may indicate bleeding.

49

The nurse is caring for clients on a surgical floor. Which client should be assessed first? 1. The client who is four (4) day post-operative abdominal surgery and is complaining of left calf pain when ambulating. 2. The client who is one (1) day post-operative hernia repair who has just been able to void 550 mL of clear amber urine. 3. The client who is five (5) day post-operative open cholecystectomy who has a T tube and is being discharged. 4. The client who is 16 hours post–abdominal hysterectomy and is complaining of abdominal pain and is expelling flatus.

1. A complication of immobility after surgery is developing a DVT. This client with left calf pain should be assessed for a DVT.

50

The male client is diagnosed with Guillain Barré syndrome (GB) and is in the intensive care unit on a ventilator. Which cardiovascular rationale explains implementing passive range of motion (ROM) exercises? 1. Passive ROM will prevent contractures from developing. 2. The client will feel better if he is able to exercise and stretch his muscles. 3. Range of motion exercises will help alleviate the pain associated with GB. 4. They help to prevent DVTs by movement of the blood through the veins.

4. One reason for performing range of motion exercises is to assist the blood vessels in the return of blood to the heart, preventing DVT.

51

The nurse and an unlicensed nursing assistant are bathing a bedfast client. Which action by the assistant warrants immediate intervention? 1. The assistant closes the door and cubicle curtain before undressing the client. 2. The assistant begins to massage and rub lotion into the client’s calf. 3. The assistant tests the temperature of the water with the wrist before starting. 4. The assistant collects all the linens and supplies and brings them to the room.

2. The assistant could dislodge a blood clot in the leg when massaging the calf. The assistant can apply lotion gently, being sure not to massage the leg.

52

The client diagnosed with a DVT is placed on a medical unit. Which nursing interventions should be implemented? Select all that apply. 1. Place sequential compression devices on both legs. 2. Instruct the client to stay in bed and not ambulate. 3. Encourage fluids and a diet high in roughage. 4. Monitor IV site every shift and PRN. 5. Assess Homans’ sign every 24 hours.

2. Clients should be on bed rest for five (5) to seven (7) days after diagnosis to allow time for the clot to adhere to the vein wall, thereby preventing embolization. 3. Bed rest and limited activity predispose the client to constipation. Fluids and diets high in fiber will help prevent constipation. Fluids will also help provide adequate fluid volume in the vasculature. 4. The client will be administered a heparin IV drip, which should be monitored.

53

The nurse is caring for a client receiving heparin sodium via constant infusion. The heparin protocol reads to increase the IV rate by 100 units/hour if the PTT is less than 50 seconds. The current PTT level is 46 seconds. The heparin comes in 500 mL of D5W with 25,000 units of heparin added. The current rate on the IV pump is 18 mL per hour. At what rate should the nurse set the pump?_______________

20 mL/hour. To determine the rate, the test taker must first determine how many units are in each mL of fluid; 25,000 divided by 500 = 50 units of heparin in each mL of fluid, and 50 divided into 100= 2, and 2 + 18 =20.

54

Which assessment data would warrant immediate intervention by the nurse? 1. The client diagnosed with DVT who complains of pain on inspiration. 2. The immobile client has refused to turn for the last three (3) hours. 3. The client who has had an open cholecystectomy does not want to breathe deeply. 4. The client who has had an inguinal hernia repair who must void before discharge.

1. A potentially life-threatening complication of DVT is a pulmonary embolus, which causes chest pain. The nurse should determine if the client has “thrown” a pulmonary embolus.

55

The client diagnosed with a DVT is on a heparin (an anticoagulant) drip at 1400 units per hour, and Coumadin (warfarin sodium; also an anticoagulant) 5 mg twice a day. Which intervention should the nurse implement first? 1. Check the PTT and PT/INR. 2. Check with the HCP to see which drug should be discontinued. 3. Administer both medications. 4. Discontinue the heparin because the client is receiving Coumadin.

1. The nurse should check the laboratory values pertaining to the medications before administering the medications.

56

Which actions should the surgical scrub nurse take to prevent from personally developing a DVT? 1. Keep the legs in a dependent position and stand as still as possible. 2. Flex the leg muscles and change the leg positions frequently. 3. Wear white socks and shoes that have a wedge heel. 4. Ask the surgeon to allow the nurse to take a break midway through each surgery.

2. Flexing the leg muscles and changing positions assist the blood to return to the heart and move out of the peripheral vessels.

57

The client receiving low molecular weight heparin (LMWH) subcutaneously to prevent DVT following hip replacement surgery complains to the nurse that there are small purple hemorrhaged areas on the upper abdomen. Which action should the nurse implement? 1. Notify the HCP immediately. 2. Check the client’s PTT level. 3. Explain that this results from the medication. 4. Assess the client’s vital signs.

3. This is not hemorrhaging, and the client should be reassured that this is a side effect of the medication.

58

The home health nurse is admitting a client diagnosed with a DVT. Which action by the client warrants immediate intervention by the nurse? 1. The client takes a stool softener every day at dinnertime. 2. The client is wearing a medic alert bracelet. 3. The client takes vitamin E over-the-counter medications. 4. The client has purchased a new recliner that will elevate the legs.

3. Vitamin E can affect the action of warfarin. The nurse should explain to the client that these and other medications could potentiate the action of warfarin.

59

The client is being admitted with Coumadin (warfarin), an anticoagulant, toxicity. Which laboratory data should the nurse monitor? 1. Blood urea nitrogen levels (BUN). 2. Bilirubin levels. 3. International Normalized Ratio (INR). 4. Partial thromboplastin time (PTT).

3. PT/INR is a test to monitor warfarin (Coumadin) action in the body.

60

The nurse is teaching a class on venous insufficiency. The nurse would identify which condition as the most serious complication of chronic venous insufficiency? 1. Arterial thrombosis. 2. Deep vein thrombosis. 3. Venous ulcerations. 4. Varicose veins.

3. Venous ulcerations are the most serious complication of chronic venous insufficiency. It is very difficult for these ulcerations to heal, and often clients must be seen in wound care clinics for treatment.

61

Which assessment data would support that the client has a venous stasis ulcer? 1. Superficial pink open area on the medial part of the ankle. 2. A deep pale open area over the top side of the foot. 3. A reddened blistered area on the heel of the foot. 4. A necrotic gangrenous area on the dorsal side of the foot.

1. The medial part of the ankle usually ulcerates because of edema that leads to stasis, which, in turn, causes the skin to break down.

62

The client is employed in a job that requires extensive standing. Which intervention should the nurse include when discussing how to prevent varicose veins? 1. Wear low-heeled, comfortable shoes. 2. Wear white, clean, cotton socks. 3. Move the legs back and forth often. 4. Wear graduated compression hose.

4. Graduated compression hose help decrease edema and increase the circulation back to the heart; this helps prevent varicose veins.

63

The client with varicose veins asks the nurse, “What caused me to have these?” Which statement by the nurse would be most appropriate? 1. “You have incompetent valves in your legs.” 2. “Your legs have decreased oxygen to the muscle.” 3. “There is an obstruction in the saphenous vein.” 4. “Your blood is thick and can’t circulate properly.”

1. Varicose veins are irregular, tortuous veins with incompetent valves that do not allow the venous blood to ascend the saphenous vein.

64

The nurse is caring for the client with chronic venous insufficiency. Which statement indicates that the client understands the discharge teaching? 1. “I shouldn’t cross my legs for more than 15 minutes.” 2. “I need to elevate the foot of my bed while sleeping.” 3. “I should take a baby aspirin every day with food.” 4. “I should increase my fluid intake to 3000 mL a day.”

2. Elevating the foot of the bed while sleeping helps the venous blood return to the heart and decreases pressure in the lower extremity.

65

The unlicensed nursing assistant is caring for the client diagnosed with chronic venous insufficiency. Which action would warrant immediate intervention from the nurse? 1. Applying compression stockings before going to bed. 2. Taking the client’s blood pressure manually. 3. Assisting the client by opening the milk on the tray. 4. Calculating the client’s shift intake and output.

1. Research shows that removing the compression stockings while the client is in bed promotes perfusion of the subcutaneous tissue. The foot of the bed should be elevated.

66

The 80-year-old client is being discharged home after having surgery to debride a chronic venous ulcer on the right ankle. Which referral would be most appropriate for the client? 1. Occupational therapist. 2. Social worker. 3. Physical therapist. 4. Cardiac rehabilitation.

2. The social worker would assess the client to determine if home health care services or financial interventions were appropriate for the client. The client is elderly, immobility is a concern, and wound care must be a concern when the client is discharged home.

67

Which assessment data would the nurse expect to find in the client diagnosed with chronic venous insufficiency? 1. Decreased pedal pulses. 2. Cool skin temperature. 3. Intermittent claudication. 4. Brown discolored skin.

4. Chronic venous insufficiency leads to chronic edema that, in turn, causes a brownish pigmentation to the skin.

68

Which client would be most at risk for developing varicose veins? 1. A Caucasian female who is a nurse. 2. An African American male who is a bus driver. 3. An Asian female with no children. 4. An elderly male with diabetes.

1. Varicose veins are more common in white females in occupations that involve prolonged standing.

69

The client with varicose veins is six (6) hours post-operative vein ligation. Which nursing intervention should the nurse implement first? 1. Assist the client to dangle the legs off the side of the bed. 2. Assess and maintain pressure bandages on the affected leg. 3. Apply a sequential compression device to the affected leg. 4. Administer the prescribed prophylactic intravenous antibiotic.

2. Pressure bandages are applied for up to six (6) weeks after vein ligation to help prevent bleeding and to help venous return from the lower extremities when in the standing or sitting position.

70

The nurse has just received the A.M. shift report. Which client would the nurse assess first? 1. The client with a venous stasis ulcer who is complaining of pain. 2. The client with varicose veins who has dull aching muscle cramps. 3. The client with arterial occlusive disease who cannot move the foot. 4. The client with deep vein thrombosis who has a positive Homans’ sign.

3. The inability to move the foot means that a severe neurovascular compromise has occurred, and the nurse should assess this client first.

71

The nurse is completing a neurovascular assessment on the client with chronic venous insufficiency. What should be included in this assessment? Select all that apply. 1. Assess for paresthesia. 2. Assess for pedal pulses. 3. Assess for paralysis. 4. Assess for pallor. 5. Assess for paresthesia.

1. The nurse should determine if the client has any numbness or tingling. 2. The nurse should determine if the client has pulses, the presence of which indicates there is no circulatory compromise. 3. The nurse should determine if the client can move the feet and legs. 4. The nurse should determine if the client’s feet are pink or pale. 5. The nurse should assess the feet to determine if they are cold or warm.

72

Which client behavior would be a causative factor for developing Buerger’s disease (thromboangiitis obliterans)? 1. Drinking alcohol daily. 2. Eating a high-fat diet. 3. Chewing tobacco. 4. Inhaling gasoline fumes.

3. Heavy smoking or chewing tobacco is a causative or aggravating factor for Buerger’s disease. Cessation of tobacco use may cause cessation of the disease process in some clients.

73

Which signs/symptoms would the nurse expect to find when assessing a client diagnosed with subclavian steal syndrome? 1. Complaints of arm tiredness with exertion. 2. Complaints of shortness of breath while resting. 3. Jugular vein distention when sitting at a 35-degree angle. 4. Dilated blood vessels above the nipple line.

1. Subclavian steal syndrome occurs in the upper extremities from a subclavian artery occlusion or stenosis, which causes arm tiredness, paresthesia, and exercise-induced pain in the forearm when the arms are elevated. This is also known as upperextremity arterial occlusive disease.

74

Which question should the nurse ask the male client diagnosed with aorto-iliac disease during the admission interview? 1. “Do you have trouble sitting for long periods of time?” 2. “How often do you have a bowel movement and urinate?” 3. “When you lie down do you feel throbbing in your abdomen?” 4. “Have you experienced any problems having sexual intercourse?”

4. Aortoiliac disease is caused by atherosclerosis of the aortoiliac arch, which causes pain in the lower back and buttocks and impotence in men.

75

The client is four (4) hours post-operative abdominal aortic aneurysm repair. Which nursing intervention should be implemented for this client? 1. Assist the client to ambulate. 2. Assess the client’s bilateral pedal pulses. 3. Maintain continuous IV heparin drip. 4. Provide a clear liquid diet to the client.

2. A neurovascular assessment is priority to make sure the graft is perfusing the lower extremities.

76

Which referral would be most appropriate for the client diagnosed with thoracic outlet syndrome? 1. The physical therapist. 2. The thoracic surgeon. 3. The occupational therapist. 4. The social worker.

1. Thoracic outlet syndrome is a compression of the subclavian artery at the thoracic outlet by an anatomical structure such as a rib or muscle. Physical therapy, exercises, and avoiding aggravating positions are recommended treatment.

77

Which instruction should the nurse discuss with the client diagnosed with Raynaud’s phenomenon? 1. Explain exacerbations will not occur in the summer. 2. Use nicotine gum to help quit smoking. 3. Wear extra warm clothing during cold exposure. 4. Avoid prolonged exposure to direct sunlight.

3. Raynaud’s phenomenon is a form of intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of fingertips or toes; therefore the client should keep warm to prevent vasoconstriction of the extremities.

78

The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first? 1. Administer intravenous antibiotics. 2. Apply warm moist packs every two (2) hours. 3. Elevate the right foot on two (2) pillows. 4. Teach the client about skin and foot care.

3. Elevating the foot above the heart will decrease edema and thereby help decrease the pain. It is the easiest and first intervention for the nurse to implement.

79

Which discharge instruction should the nurse discuss with the client to prevent recurrent episodes of cellulitis? 1. Soak your feet daily in Epsom salts for 20 minutes. 2. Wear thick white socks when working in the yard. 3. Use a mosquito repellant when going outside. 4. Inspect the foot between the toes for cracks in the skin.

4. The key to preventing cellulitis is identifying the sites of bacterial entry. The most commonly overlooked areas are the cracks and fissures that occur between the toes.

80

Which discharge instruction should the nurse teach the client diagnosed with varicose veins who has received sclerotherapy? 1. Walk 15 to 20 minutes three (3) times a day. 2. Keep the legs in the dependent position when sitting. 3. Remove compression bandages before going to bed. 4. Perform Berger-Allen exercises four (4) times a day.

1. After sclerotherapy clients are taught to perform walking activities to maintain blood flow in the leg and enhance dilution of the sclerosing agent.

81

The nurse is teaching the client with peripheral vascular disease. Which interventions should the nurse discuss with the client? Select all that apply. 1. Wash your feet in antimicrobial soap. 2. Wear comfortable, well-fitting shoes. 3. Cut your toenails in an arch. 4. Keep the area between the toes dry. 5. Use a heating pad when feet are cold.

2. Shoes must be comfortable to prevent blisters or ulcerations of the feet. 4. Moisture between the toes increases fungal growth, leading to skin breakdown.

82

The unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant would warrant immediate intervention by the nurse? 1. The assistant is putting the stockings on while the client is in the chair. 2. The assistant inserted two (2) fingers under the proximal end of the stocking. 3. The assistant elevated the feet while lying down prior to putting on the stockings. 4. The assistant made sure the toes were warm after putting the stockings on.

1. Stockings should be applied after the legs have been elevated for a period of time when the amount of blood in the leg vein is at its lowest; therefore, the nurse should intervene when the assistant is putting them on while the client is in the chair.

83

The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause the nurse to question administering the medication? 1. The client’s BP is 110/70. 2. The client’s potassium level is 3.4 mEq/L. 3. The client has a barky cough. 4. The client’s apical pulse is 56.

4. The beta blocker decreases sympathetic stimulation to the beta cells of the heart. Therefore, the nurse should question administering the medication if the apical pulse is less than 60 beats per minute.

84

The client diagnosed with acute deep vein thrombosis is receiving a continuous heparin drip, an intravenous anticoagulant. The health-care provider orders warfarin (Coumadin), an oral anticoagulant. Which action should the nurse take? 1. Discontinue the heparin drip prior to initiating the Coumadin. 2. Check the client’s INR prior to beginning Coumadin. 3. Clarify the order with the health-care provider as soon as possible. 4. Administer the Coumadin along with the heparin drip as ordered.

4. It will require several days for the Coumadin to reach therapeutic levels; the client will continue receiving the heparin drip until the therapeutic range can be attained.

85

The nurse is caring for the client on strict bed rest. Which intervention is priority when caring for this client? 1. Encourage the client to drink liquids. 2. Perform active range of motion exercises. 3. Elevate the head of the bed to 45 degrees. 4. Provide a high-fiber diet to the client.

2. Preventing deep vein thrombosis is the priority nursing intervention because the client is on strict bed rest; ROM exercises should be done every four (4) hours.

86

The nurse is caring for clients on a medical floor. Which client will the nurse assess first? 1. The client with an abdominal aortic aneurysm who is constipated. 2. The client on bed rest who ambulated to the bathroom. 3. The client with essential hypertension who has epistaxis and a headache. 4. The client with arterial occlusive disease who has a decreased pedal pulse.

3. A bloody nose and a headache indicate the client is experiencing very high blood pressure and should be assessed first because of a possible myocardial infarction or stroke.

87

The client with peripheral venous disease is scheduled to go to the whirlpool for a dressing change. Which is the nurse’s priority intervention? 1. Escort the client to the physical therapy department. 2. Medicate the client 30 minutes before going to whirlpool. 3. Obtain the sterile dressing supplies for the client. 4. Assist the client to the bathroom prior to the treatment.

2. The client’s pain is priority, and the nurse should premedicate prior to treatment.

88

The client is receiving prophylactic low molecular weight heparin. There is no PT/PTT, INR on the client’s chart since admission three (3) days ago. Which action should the nurse implement? 1. Administer the medication as ordered. 2. Notify the health-care provider immediately. 3. Obtain a PT/PTT, INR prior to administering. 4. Hold the medication until the HCP makes rounds.

1. Subcutaneous heparin will not achieve a therapeutic level because of the short halflife of the medication; therefore the nurse should administer the medication.

89

The client diagnosed with atherosclerosis asks the nurse, “I have heard of atherosclerosis for many years but I never really knew what it meant. Am I going to die?” Which statement would be the nurse’s best response? 1. “This disease process will not kill you, so don’t worry.” 2. “The blood supply to your brain is being cut off.” 3. “It is what caused you to have your high blood pressure.” 4. “Atherosclerosis is a buildup of plaque in your arteries.”

4. A buildup of plaque in the arteries is occurring in the body when the client has atherosclerosis.

90

Which signs/symptoms would the nurse expect to find in the female client diagnosed with Marfan’s syndrome? 1. Xerostomia, dry eyes, and complaints of a dry vagina. 2. A triad of arthritis, conjunctivitis, and urethritis. 3. Very tall stature and long bones in the hands and feet. 4. Spinal deformities of the vertebral column and malaise.

3. Clients with Marfan’s syndrome are very tall and have long bones in the hands and feet. They also have abnormalities of the cardiovascular system resulting in valvular problems and aneurysms, which are the leading cause of death during the late 20s.

91

The nurse is preparing to administer 7.5 mg of an oral anticoagulant. The medication available is 5 mg per tablet. How many tablets should the nurse administer?_________

1.5 tablets. The nurse must score one tablet and administer one and a half tablets to ensure that the correct dose is administered.

92

Which dietary selection indicates the client with essential hypertension understands the discharge teaching? 1. Fried pork chops, a loaded baked potato, and coffee. 2. Spaghetti and meatballs, garlic bread, and iced tea. 3. Baked ham, macaroni and cheese, and milk. 4. Broiled fish, steamed broccoli, and garden salad.

4. The client should be eating a low-fat, lowcholesterol, low-sodium diet. This meal reflects this diet.

93

The client diagnosed with Buerger’s disease (thromboangiitis obliterans) asks the nurse, “What is the worse thing that could happen if I don’t quit smoking? I love my cigarettes.” Which statement is the nurse’s best response? 1. “You are concerned about quitting smoking. Let’s sit down and talk about it.” 2. “Many clients end up having to have an amputation, especially a leg.” 3. “If you are worried about quitting, you should attend Smokenders.” 4. “Your coronary arteries could block and cause a heart attack.”

2. Smoking aggravates Buerger’s disease. Aggravated or severe Buerger’s disease can lead to arterial occlusion caused by superficial thrombophlebitis causing poor wound healing and poor circulation. This can lead to the need for amputation.

94

The client diagnosed with subclavian steal syndrome has undergone surgery. Which assessment data would warrant immediate intervention by the nurse? 1. The client’s pedal pulse on the left leg is absent. 2. The client complains of numbness in the right hand. 3. The client’s brachial pulse is strong and bounding. 4. The client’s capillary refill time (CRT) is three (3) seconds.

2. Subclavian steal syndrome occurs in the upper extremities from a subclavian artery occlusion or stenosis; therefore, any abnormal neurovascular assessment would warrant intervention.

95

The client with a left-sided mastectomy is diagnosed with elephantiasis of the left arm. Which signs/symptoms should the nurse expect to assess? 1. Edematous arm from axillary area to fingertips. 2. Painful edematous reddened lower forearm. 3. Tented skin turgor over the entire left arm. 4. Nipple retraction and peau d’orange skin.

1. Elephantiasis is obstruction of the lymphatic vessels that causes chronic fibrosis, thickening of the subcutaneous tissue, and hypertrophy of the skin; this condition causes chronic edema of the extremity that recedes only slightly with elevation.

96

The client is four (4) hours post-operative femoral–popliteal bypass surgery. Which pulse would be best for the nurse to assess for complications related to an occluded vessel?

 

1. A 2. B 3. C 4. D

4. The pedal pulse is the best pulse to assess because it indicates if there is adequate circulation to the most distal site of the extremity. The bypass extends from the midthigh to the mid-calf area.

97

The client admitted with a diagnosis of pneumonia complains of tenderness and pain in the left calf, and the nurse assesses a positive Homans’ sign. Which interventions should the nurse implement? List in order of priority. 1. Notify the health-care provider. 2. Initiate an intravenous line. 3. Monitor the client’s PTT. 4. Administer a continuous heparin infusion. 5. Instruct the client not to get out of the bed.

In order of priority: 5, 1, 2, 4, 3 5. The nurse should suspect a deep vein thrombosis and should not allow the client to get out of the bed. 1. This is a medical emergency and the HCP should be notified as soon as possible. 2. The client needs an intravenous line so that IV heparin can be administered. 4. The treatment for DVT is to prevent further coagulation until the clot dissolves. 3. The client’s PTT is monitored when receiving heparin therapy.

98

A nurse is caring for a patient with a diagnosis of deep venous thrombosis (DVT). The patient has an order to receive 30 mg enoxaparin (Lovenox). Which injection site should the nurse use to administer this medication safely? A. Buttock, upper outer quadrant B. Abdomen, anterior-lateral aspect C. Back of the arm, 2 inches away from a mole D. Anterolateral thigh, with no scar tissue nearby

B. Enoxaparin (Lovenox) is a low-molecular-weight (LMW) heparin that is given as a deep subcutaneous injection in the right and left anterolateral abdomen. All subcutaneous injections should be given away from scars, lesions, or moles.

99

The nurse is preparing to administer a scheduled dose of enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to administer this medication correctly? A. Remove the air bubble in the prefilled syringe. B. Aspirate before injection to prevent IV administration. C. Rub the injection site after administration to enhance absorption. D. Pinch the skin between the thumb and forefinger before inserting the needle.

D. The nurse should gather together or "bunch up" the skin between the thumb and the forefinger before inserting the needle into the subcutaneous tissue. The nurse should not remove the air bubble in the prefilled syringe, aspirate, nor rub the site after injection.

100

The nurse is admitting a 68-year-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication? A. Vitamin K B. Cobalamin C. Heparin sodium D. Protamine sulfate

A. Coumadin is a Vitamin K antagonist anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin (Coumadin).

101

The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed? A. Decreased cardiac output B. Increased blood pressure C. Cerebral or pulmonary emboli D. Excessive bleeding from incision or IV sites

C. Warfarin is an anticoagulant that is used to prevent thrombi from forming on the walls of the atria during atrial fibrillation. Once the medication is terminated, thrombi could again form. If one or more thrombi detach from the atrial wall, they could travel as cerebral emboli from the left atrium or pulmonary emboli from the right atrium.

102

The nurse is reviewing the laboratory test results for a 68-year-old patient whose warfarin (Coumadin) therapy was terminated during the preoperative period. The nurse concludes that the patient is in the most stable condition for surgery after noting which INR (international normalized ratio) result? A. 1.0 B. 1.8 C. 2.7 D. 3.4

A. The therapeutic range for INR is 2.0 to 3.0 for many clinical diagnoses. The larger the INR number, the greater the amount of anticoagulation. For this reason, the safest value before surgery is 1.0, meaning that the anticoagulation has been reversed.

103

The nurse would determine that a postoperative patient is not receiving the beneficial effects of enoxaparin (Lovenox) after noting what during a routine shift assessment? A. Generalized weakness and fatigue B. Crackles bilaterally in the lung bases C. Pain and swelling in lower extremity D. Abdominal pain with decreased bowel sounds

C. Enoxaparin is a low-molecular-weight heparin used to prevent the development of deep vein thromboses (DVTs) in the postoperative period. Pain and swelling in the lower extremity can indicate development of DVT and therefore may signal ineffective medication therapy.

104

The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT). The patient now needs to undergo surgery for appendicitis. The nurse is reviewing the laboratory results for this patient before administering an ordered dose of vitamin K. The nurse determines that the medication is both safe to give and is most needed when the international normalized ratio (INR) is which result? A. 1.0 B. 1.2 C. 1.6 D. 2.2

D. Vitamin K is the antidote to warfarin (Coumadin), which the patient has most likely been taking before admission for treatment of DVT. Warfarin is an anticoagulant that impairs the ability of the blood to clot. Therefore it is necessary to give vitamin K before surgery to reduce the risk of hemorrhage. The largest value of the INR indicates the greatest impairment of clotting ability, making 2.2 the correct selection.

105

A postoperative patient asks the nurse why the physician ordered daily administration of enoxaparin (Lovenox). Which reply by the nurse is most appropriate? A. "This medication will help prevent breathing problems after surgery, such as pneumonia." B. "This medication will help lower your blood pressure to a safer level, which is very important after surgery." C. "This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal." D. "This medication is a narcotic pain medication that will help take away any muscle aches caused by positioning on the operating room table."

C. Enoxaparin is an anticoagulant that is used to prevent DVTs postoperatively. All other explanations/options do not describe the action/purpose of enoxaparin.

106

The nurse is caring for a preoperative patient who has an order for vitamin K by subcutaneous injection. The nurse should verify that which laboratory study is abnormal before administering the dose? A. Hematocrit (Hct) B. Hemoglobin (Hgb) C. Prothrombin time (PT) D. Partial thromboplastin time (PTT)

C. Vitamin K counteracts hypoprothrombinemia and/or reverses the effects of warfarin (Coumadin) and thus decreases the risk of bleeding. High values for either the prothrombin time (PT) or the international normalized ratio (INR) demonstrates the need for this medication.

107

The nurse is caring for a newly admitted patient with vascular insufficiency. The patient has a new order for enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to correctly administer this medication? A. Spread the skin before inserting the needle. B. Leave the air bubble in the prefilled syringe. C. Use the back of the arm as the preferred site. D. Sit the patient at a 30-degree angle before administration.

B. The nurse should not expel the air bubble from the prefilled syringe because it should be injected to clear the needle of medication and avoid leaving medication in the needle track in the tissue.

108

What is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)? A. Application of topical antibiotics to venous ulcers B. Maintaining the patient's legs in a dependent position C. Administration of oral and/or subcutaneous anticoagulants D. Teaching the patient the correct use of compression stockings

D. CVI requires conscientious and consistent application of compression stockings. Anticoagulants are not necessarily indicated and antibiotics, if required, are typically oral or IV, not topical. The patient should avoid prolonged positioning with the limb in a dependent position.

109

A patient with varicose veins has been prescribed compression stockings. How should the nurse teach the patient to use these? A. "Try to keep your stockings on 24 hours a day, as much as possible." B. "While you're still lying in bed in the morning, put on your stockings." C. "Dangle your feet at your bedside for 5 minutes before putting on your stockings." D. "Your stockings will be most effective if you can remove them for a few minutes several times a day."

B. The patient with varicose veins should apply stockings in bed, before rising in the morning. Stockings should not be worn continuously, but they should not be removed several times daily. Dangling at the bedside prior to application is likely to decrease their effectiveness.

110

Assessment of a patient's peripheral IV site reveals that phlebitis has developed over the past several hours. Which intervention should the nurse implement first? A. Remove the patient's IV catheter. B. Apply an ice pack to the affected area. C. Decrease the IV rate to 20 to 30 mL/hr. D. Administer prophylactic anticoagulants.

A. The priority intervention for superficial phlebitis is removal of the offending IV catheter. Decreasing the IV rate is insufficient. Anticoagulants are not normally required, and warm, moist heat is often therapeutic.

111

A 62-year-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral artery disease (PAD). The patient is a smoker and has a history of gout. What should the nurse focus her teaching on to prevent complications for this patient? A. Gender B. Smoking C. Ethnicity D. Co-morbidities

B. Smoking is the most significant factor for this patient. PAD is a marker of advanced systemic atherosclerosis. Therefore tobacco cessation is essential to reduce PAD progression, CVD events, and mortality. Diabetes mellitus and hyperuricemia are also risk factors. Being male or Hispanic are not risk factors for PAD.

112

What medications should the nurse expect to include in the teaching plan to decrease the risk of cardiovascular events and death for PAD patients (select all that apply)? A. Ramipril (Altace) B. Cilostazol (Pletal) C. Simvastatin (Zocor) D. Clopidogrel (Plavix) E. Warfarin (Coumadin) F. Aspirin (acetylsalicylic acid)

A. C. F. Angiotensin-converting enzyme inhibitors (e.g., ramipril [Altace]) are used to control hypertension. Statins (e.g., simvastatin [Zocor]) are used for lipid management. Aspirin is used as an antiplatelet agent. Cilostazol (Pletal) is used for intermittent claudication, but it does not reduce CVD morbidity and mortality risks. Clopidogrel may be used if the patient cannot tolerate aspirin. Anticoagulants (e.g., warfarin [Coumadin]) are not recommended to prevent CVD events in PAD patients.

113

A female patient with critical limb ischemia has had peripheral artery bypass surgery to improve her circulation. What care should the nurse provide on postoperative day 1? A. Keep the patient on bed rest. B. Assist the patient with walking several times. C. Have the patient sit in the chair several times. D. Place the patient on her side with knees flexed.

B. To avoid blockage of the graft or stent, the patient should walk several times on postoperative day 1 and subsequent days. Having the patient's knees flexed for sitting in a chair or in bed increase the risk of venous thrombosis and may place stress on the suture lines.

114

A patient was just diagnosed with acute arterial ischemia in the left leg secondary to atrial fibrillation. Which early clinical manifestation must be reported to the physician immediately to save the patient's limb? A. Paralysis B. Paresthesia C. Crampiness D. Referred pain

B. The physician must be notified immediately if any of the six Ps of acute arterial ischemia occur to prevent ischemia from quickly progressing to tissue necrosis and gangrene. The six Ps are paresthesia, pain, pallor, pulselessness, and poikilothermia, with paralysis being a very late sign indicating the death of nerves to the extremity. Crampy leg sensation is more common with varicose veins. The pain is not referred.

115

A 40-year-old man tells the nurse he has a diagnosis for the color and temperature changes of his limbs but can't remember the name of it. He says he must stop smoking and avoid trauma and exposure of his limbs to cold temperatures to get better. This description should allow the nurse to ask the patient if he has which diagnosis? A. Buerger's disease B. Venous thrombosis C. Acute arterial ischemia D. Raynaud's phenomenon

A. Buerger's disease is a nonatherosclerotic, segmental, recurrent inflammatory disorder of small and medium-sized veins and arteries of upper and lower extremities leading to color and temperature changes of the limbs, intermittent claudication, rest pain, and ischemic ulcerations. It primarily occurs in men younger than 45 years old with a long history of tobacco and/or marijuana use. Buerger's disease treatment includes smoking cessation, trauma and cold temperature avoidance, and a walking program. Venous thrombosis is the formation of a thrombus in association with inflammation of the vein. Acute arterial ischemia is a sudden interruption in arterial blood flow to a tissue caused by embolism, thrombosis, or trauma. Raynaud's phenomenon is characterized by vasospasm-induced color changes of the fingers, toes, ears, and nose.

116

A male patient was admitted for a possible ruptured aortic aneurysm, but had no back pain. Ten minutes later his assessment includes the following: sinus tachycardia at 138, BP palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret this assessment about the patient's aneurysm? A. Tamponade will soon occur. B. The renal arteries are involved. C. Perfusion to the legs is impaired. D. He is bleeding into the abdomen.

D. The lack of back pain indicates the patient is most likely exsanguinating into the abdominal space, and the bleeding is likely to continue without surgical repair. A blockade of the blood flow will not occur in the abdominal space as it would in the retroperitoneal space where surrounding anatomic structures may control the bleeding. The lack of urine output does not indicate renal artery involvement, but that the bleeding is occurring above the renal arteries, which decreases the blood flow to the kidneys. There is no assessment data indicating decreased perfusion to the legs.

117

The patient had aortic aneurysm repair. What priority nursing action will the nurse use to maintain graft patency? A. Assess output for renal dysfunction. B. Use IV fluids to maintain adequate BP. C. Use oral antihypertensives to maintain cardiac output. D. Maintain a low BP to prevent pressure on surgical site

B. The priority is to maintain an adequate BP (determined by the surgeon) to maintain graft patency. A prolonged low BP may result in graft thrombosis, and hypertension may cause undue stress on arterial anastomoses resulting in leakage of blood or rupture at the suture lines, which is when IV antihypertensives may be used. Renal output will be assessed when the aneurysm repair is above the renal arteries to assess graft patency, not maintain it.

118

When the patient is being examined for venous thromboembolism (VTE) in the calf, what diagnostic test should the nurse expect to teach the patient about first? A. Duplex ultrasound B. Contrast venography C. Magnetic resonance venography D. Computed tomography venography

A. The duplex ultrasound is the most widely used test to diagnose VTE. Contrast venography is rarely used now. Magnetic resonance venography is less accurate for calf veins than pelvic and proximal veins. Computed tomography venography may be used but is invasive and much more expensive than the duplex ultrasound.

119

The patient reports tenderness when she touches her leg over a vein. The nurse assesses warmth and a palpable cord in the area. The nurse knows the patient needs treatment to prevent which sequelae? A. Pulmonary embolism B. Pulmonary hypertension C. Post-thrombotic syndrome D. Venous thromboembolism

D. The clinical manifestations are characteristic of a superficial vein thrombosis. If untreated, the clot may extend to deeper veins, and venous thromboembolism may occur. Pulmonary embolism, pulmonary hypertension, and post-thrombotic syndrome are the sequelae of venous thromboembolism.

120

The patient has CVI and a venous ulcer. The unlicensed assistive personnel (UAP) decides to apply compression stockings because that is what these patients always have ordered. What assessment by the nurse would cause the application of compression stockings to harm the patient? A. Rest pain B. High blood pressure C. Elevated blood sugar D. Dry, itchy, flaky skin

A. Rest pain occurs as peripheral artery disease (PAD) progresses and involves multiple arterial segments. Compression stockings should not be used on patients with PAD. Elevated blood glucose, possibly indicating uncontrolled diabetes mellitus, and hypertension may or may not indicate arterial problems. Dry, itchy, flaky skin indicates venous insufficiency. The RN should be the one to obtain the order and instruct the UAP to apply compression stockings if they are ordered.

121