PV Chapter 37 Flashcards
(36 cards)
Which risk factor should the nurse focus on when teaching a patient who has a 5-cm
abdominal aortic aneurysm?
a. Male gender
b. Turner syndrome
c. Abdominal trauma history
d. Uncontrolled hypertension
ANS: D
All 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.
Which finding on a patient’s nursing admission assessment is congruent with the initial
medical diagnosis of a 6-cm thoracic aortic aneurysm?
a. Low back pain
b. Trouble swallowing
c. Abdominal tenderness
d. Changes in bowel habits
ANS: B
Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the
esophagus. The other symptoms will be important to assess for in patients with abdominal
aortic aneurysms.
Several hours after a patient had 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 45 mL. What should
the nurse anticipate will be prescribed?
a. Hemoglobin count
b. Increased IV fluids
c. Additional antibiotics
d. Serum creatinine level
ANS: B
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.
Which group of drugs will the nurse plan to include when teaching a patient who has a new
diagnosis of peripheral artery disease (PAD)?
a. Statins
b. Antibiotics
c. Thrombolytics
d. Anticoagulants
ANS: A
Research indicates that statin use by patients with PAD improves multiple outcomes. There is
no research that supports the use of the other drug categories in PAD.
An older patient with chronic atrial fibrillation develops sudden severe pain, pulselessness,
pallor, and coolness in the right leg. After the nurse notifies the health care provider, what
should the nurse do next?
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.
ANS: D
The patient’s history and clinical manifestations are consistent with acute arterial occlusion.
Resting the leg will decrease the O2 demand of the tissues and minimize ischemic damage
until circulation can be restored. Elevating the leg or applying an elastic wrap will further
compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the
leg.
A patient at the clinic says, “I always walk after dinner, but lately my leg cramps and hurts
after just a few minutes. The pain goes away after I stop walking, though.” What focused
assessment should the nurse make?
a. Look 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. Palpate for the presence of dorsalis pedis and posterior tibial pulses.
ANS: D
The nurse should assess for other clinical manifestations of peripheral arterial disease in a
patient who describes intermittent claudication. Changes in skin color that occur in response
to cold are consistent with Raynaud’s phenomenon. Tortuous veins on the legs suggest venous
insufficiency. Unilateral leg swelling, redness, and tenderness indicate venous
thromboembolism.
A patient has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right
second toe. What should the nurse expect to find on assessment?
a. Dilated superficial veins.
b. Swollen, dry, scaly ankles.
c. Prolonged capillary refill in all the toes.
d. Serosanguineous drainage from the ulcer.
ANS: C
Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the
periphery. The other listed clinical manifestations are consistent with chronic venous disease
The nurse is evaluating the discharge teaching outcomes for a patient with chronic peripheral
artery disease (PAD). Which patient statement indicates a need for further instruction?
a. “I will buy loose clothes that do not bind across my legs or waist.”
b. “I will use a heating pad on my feet at night to increase the circulation.”
c. “I will walk to the point of pain, rest, and walk again for at least 30 minutes 3
times a week.”
d. “I will change my position every hour and avoid long periods of sitting with my
legs crossed.”
ANS: B
Because the patient has impaired circulation and sensation to the feet, the use of a heating pad
could lead to burns. The other patient statements are correct and indicate that teaching has
been successful.
Which action by the patient with newly diagnosed Raynaud’s phenomenon best demonstrates
that the nurse’s teaching about managing the condition has been effective?
a. The patient exercises indoors during the winter months.
b. The patient immerses hands in hot water when they turn pale.
c. The patient takes pseudoephedrine (Sudafed) for cold symptoms.
d. The patient avoids taking nonsteroidal antiinflammatory drugs (NSAIDs).
ANS: A
Patients should avoid temperature extremes by exercising indoors when it is cold. To avoid
burn injuries, the patient should use warm rather than hot water to warm the hands.
Pseudoephedrine is a vasoconstrictor and should be avoided. There is no reason to avoid
taking NSAIDs with Raynaud’s phenomenon.
The health care provider has prescribed bed rest with the feet elevated for a patient admitted to
the hospital with venous thromboembolism of the left lower leg. Which action by the nurse is
best?
a. The patient’s bed is placed in the Trendelenburg position.
b. Two pillows are positioned under the calf of the affected leg.
c. The bed is elevated at the knee and pillows are placed under both feet.
d. One pillow is placed under the thighs and 2 pillows are under the lower legs.
ANS: D
The purpose of elevating the feet is to enhance venous flow from the feet to the right atrium,
which is best accomplished by placing 2 pillows under the feet and another under the thighs.
Placing the patient in the Trendelenburg position will lower the head below heart level, which
is not indicated for this patient. Placing pillows under the calf or elevating the bed at the knee
may cause blood stasis at the calf level.
The health care provider prescribes an infusion of heparin and daily partial thromboplastin
time (PTT) testing for a patient with venous thromboembolism (VTE). Which action should
the nurse include in the plan of care?
a. Obtain a Doppler for monitoring bilateral pedal pulses.
b. Decrease the infusion when the PTT value is 65 seconds.
c. Avoid giving IM medications to prevent localized bleeding.
d. Have vitamin K available in case reversal of the heparin is needed.
ANS: C
Intramuscular injections are avoided in patients receiving anticoagulation to prevent
hematoma formation and bleeding from the site. A PTT of 65 seconds is within the
therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by VTE.
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. “Taking both blood thinners greatly reduces the risk for another clot to form.”
b. “Enoxaparin will work right away, but warfarin takes several days to begin
preventing clots.”
c. “Enoxaparin will start to dissolve the clot, and warfarin will prevent any more
clots from forming.”
d. “Because of the risk for a blood clot in the lungs, it is important for you to take
more than one blood thinner.”
ANS: B
Low-molecular-weight heparin (LMWH) is used because of the immediate effect on
coagulation and discontinued once the international normalized ratio (INR) value indicates
that the warfarin has reached a therapeutic level. LMWH has no thrombolytic properties. The
use of two anticoagulants is not related to the risk for pulmonary embolism, and two are not
necessary to reduce the risk for another VTE. Anticoagulants do not thin the blood.
The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin)
after hospitalization for venous thromboembolism (VTE). Which patient statement indicates a
need for additional teaching?
a. “I should get a Medic Alert device stating that I take warfarin.”
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 warfarin.”
d. “I will check with my health care provider before I begin any new drugs.”
ANS: B
Teach patients taking warfarin to follow a consistent diet regarding foods that are high in
vitamin K, such as green, leafy vegetables. The other patient statements are accurate.
A 46-yr-old service-counter worker undergoes sclerotherapy for treatment of superficial
varicose veins at an outpatient center. Which instructions should the nurse provide to the
patient before discharge?
a. Sitting at the work counter, rather than standing, is recommended.
b. Exercise, such as walking or jogging, can cause recurrence of varicosities.
c. Elastic compression stockings should be applied before getting out of bed.
d. Taking an aspirin daily will help prevent clots from forming around venous valves.
ANS: C
Elastic compression stockings are applied with the legs elevated to reduce pressure in the
lower legs. Walking is recommended to prevent recurrent varicosities. Sitting and standing are
both risk factors for varicose veins and venous insufficiency. An aspirin a day is not adequate
to prevent venous thrombosis and would not be recommended for a patient who had just had
sclerotherapy.
Which topic should the nurse include in teaching for a patient with a venous stasis ulcer on the
lower leg?
a. Need to increase carbohydrate intake
b. Methods of keeping the wound area dry
c. Purpose of prophylactic antibiotic therapy
d. Application of elastic compression stockings
ANS: D
Compression of the leg is essential to healing of venous stasis ulcers. High dietary intake of
protein, rather than carbohydrates, is needed. Prophylactic antibiotics are not routinely used
for venous ulcers. Moist dressings are used to hasten wound healing.
Which patient statement to the nurse is most consistent with the diagnosis of venous
insufficiency?
a. “I can’t get my shoes on at the end of the day.”
b. “I can’t ever seem to get my feet warm enough.”
c. “I have burning leg pain after I walk two blocks.”
d. “I wake up during the night because my legs hurt.”
ANS: A
Because the edema associated with venous insufficiency increases when the patient has been
standing, shoes will feel tighter at the end of the day. The other patient statements are
characteristic of peripheral artery disease.
Which nursing action should be included in the plan of care after endovascular repair of an
abdominal aortic aneurysm?
a. Record hourly chest tube drainage.
b. Monitor fluid intake and urine output.
c. Assess the abdominal incision for redness.
d. Counsel the patient to plan for a long recovery time.
ANS: B
Because renal artery occlusion can occur after endovascular repair, the nurse should monitor
parameters of renal function such as intake and output. Chest tubes will not be needed for
endovascular surgery, the recovery period will be short, and there will not be an abdominal
wound.
Which action by a nurse who is giving fondaparinux (Arixtra) to a patient with a lower leg
venous thromboembolism (VTE) indicates that the nurse needs further education about the
drug?
a. The nurse avoids rubbing the site after giving the injection.
b. The nurse injects the drug into the abdominal subcutaneous tissue.
c. The nurse ejects the air bubble from the syringe before giving the drug.
d. The nurse does not check partial thromboplastin time (PTT) before giving the
drug.
ANS: C
The air bubble is not ejected before giving fondaparinux to avoid loss of drug. The other
actions by the nurse are appropriate for subcutaneous administration of a
low-molecular-weight heparin (LMWH). LMWHs typically do not require ongoing PTT
monitoring and dose adjustment.
A young adult patient tells the health care provider about experiencing cold, numb fingers and
Raynaud’s phenomenon is suspected. What type of testing should the nurse anticipate
explaining to the patient?
a. Hyperglycemia
b. Hyperlipidemia
c. Autoimmune disorders
d. Coronary artery disease
ANS: C
Secondary Raynaud’s phenomenon may occur in conjunction with autoimmune diseases such
as rheumatoid arthritis. Patients should be screened for autoimmune disorders. Raynaud’s
phenomenon is not associated with hyperlipidemia, hyperglycemia, or coronary artery disease.
Which patient statement supports a history of intermittent claudication?
a. “When I stand too long, my feet start to swell.”
b. “My legs cramp when I walk more than a block.”
c. “I get short of breath when I climb a lot of stairs.”
d. “My fingers hurt when I go outside in cold weather.”
ANS: B
Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent
claudication. Finger pain associated with cold weather is typical of Raynaud’s phenomenon.
Shortness of breath that occurs with exercise is not typical of intermittent claudication, which
is reproducible. Swelling associated with prolonged standing is typical of venous disease.
Which instructions should the nurse include in a teaching plan for an older adult patient newly
diagnosed with peripheral artery disease (PAD)?
a. “Exercise only if you do not experience any pain.”
b. “It is very important that you stop smoking cigarettes.”
c. “Try to keep your legs elevated whenever you are sitting.”
d. “Put elastic compression stockings on early in the morning.”
ANS: B
Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia
and reducing the risk of myocardial infarction and death. Circulation to the legs will decrease
if the legs are elevated. Patients with PAD are taught to exercise to the point of feeling pain,
rest, and then resume walking. Support hose are not used for patients with PAD.
An older patient with a history of an abdominal aortic aneurysm arrives at the emergency
department (ED) with severe back pain and absent pedal pulses. Which action should the
nurse take first?
a. Draw blood for laboratory testing.
b. Check the patient’s blood pressure.
c. Assess the patient for an abdominal bruit.
d. Determine any family history of heart disease.
ANS: B
Because the patient appears to be experiencing aortic dissection, the nurse’s first action should
be to determine the hemodynamic status by assessing blood pressure. The other actions may
also be done, but they will not provide information to determine what interventions are needed
immediately.
After receiving change-of-shift report, which patient admitted to the emergency department
should the nurse assess first?
a. A 67-yr-old patient who has a gangrenous foot ulcer with a weak pedal pulse
b. A 50-yr-old patient who is reporting sudden sharp and severe upper back pain
c. A 39-yr-old patient who has right calf tenderness and swelling after a plane ride
d. A 58-yr-old patient taking anticoagulants for atrial fibrillation who has black stools
ANS: B
The patient’s presentation of sudden sharp and severe upper back pain is consistent with
dissecting thoracic aneurysm, which will require the most rapid intervention. The other
patients also require rapid intervention but not before the patient with severe pain.
The nurse is caring for a patient immediately after repair of an abdominal aortic aneurysm. On
assessment, the patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The
legs are cool and mottled. Which action should the nurse take first?
a. Wrap both legs in a warming blanket.
b. Notify the surgeon and anesthesiologist.
c. Document the findings and recheck in 15 minutes.
d. Compare findings to the preoperative assessment of the pulses.
ANS: B
Lower extremity pulses may be absent for a short time after surgery because of vasospasm
and hypothermia. Decreased or absent pulses together with a cool and mottled extremity may
indicate embolization or graft occlusion. These findings should be reported to the surgeon
immediately because this is an emergency situation. Because pulses are marked before
surgery, the nurse would know whether pulses were present before surgery before notifying
the health care providers about the absent pulses. Because the patient’s symptoms may
indicate graft occlusion or multiple emboli and a possible need to return to surgery, it is not
appropriate to wait 15 minutes before taking action. A warming blanket will not improve the
circulation to the patient’s legs.
