ch 26 vasulcar disorders and peripheral circulation

Question 1

patient pain left lower leg, edematous and hairless, what health problem

Answer 1

intermittent claudication

Question 2

ankle brachial index abi of right leg is 0.40 how would you follow up

Answer 2

implement interventions relevant to arterial narrowing

Question 3

post op plan of care for oral contraceptives

Answer 3

early ambulation and leg exercises, bc use increases blood coagulbility

Question 4

nurse education venous insufficiency

Answer 4

avoid normal stockings that are tight

Question 5

large venous leg ulcer - how prevent infection and promote healing

Answer 5

provide high calorie, high protein diet

Question 6

nursing diagnosis - lymphedema

Answer 6

risk for infection related to lower extremity swelling secondary to lymphedema

Question 7

preventative measure for varicose veins

Answer 7

walk every hour to promote circulation

Question 8

visible red streak running up foot and ankle after stepping on nail

Answer 8

lymphangitis

Question 9

hit and swollen leg, history of chronic venous insufficiency- what intervention

Answer 9

antibiotics to treat cellulitis

Question 10

history of heart failure and peripheral arterial disease cannot ambulate - prevent which complication?

Answer 10

deep vein thrombosis

Question 11

most appropriate interventions for altered peripheral tissue perfusion related to compromised circulation

Answer 11

encourage client to engage in moderate amount of exercise

Question 12

intervention venous insufficiency

Answer 12

elevate lower extremities

Question 13

client prescribed walk for 10 min 3 times a day following MI what is relationship between walking and heart function

Answer 13

when you walk the muscles in your legs contract and pump the blood in your veins back to your heart, which allows more blood to return to your heart

Question 14

deep vein thrombophlebitis - lab values that indicate warfarin is at therapeutic levels

Answer 14

international normalized ratio (INR) between 2 and 3

Question 15

leg pain, type 1 diabetes, smokes a pack a day - nursing education for diagnosis of intermittent claudication

Answer 15

be sure to practice meticulous foot care

Question 16

femoral to popliteal bypass graft surgery- first post op assessment

Answer 16

assess pulse of affected extremity every 15 minutes

Question 17

raynaud phenomenon - nursing diagnosis

Answer 17

ineffective tissue perfusion

Question 18

inability to grasp object w right hand, cool to the touch and bp 20 more than left side - which health problem

Answer 18

upper extremity arterial occlusive disease

Question 19

gangrene on toe - which health problem

Answer 19

peripheral artery disease

Question 20

patient on Xa inhibitor, comorbidity with real insufficiency

Answer 20

lower doses of Xa inhibitors are required

Question 21

nursing action for varicose veins during pregnancy

Answer 21

teach client that circulatory changes during pregnancy frequently cause vv

Question 22

nursing education for compression stockings for venous insufficiency

Answer 22

the importance of ensuring the stockings are applied evenly with no pressure points

Question 23

priority risk for leg ulcer

Answer 23

insufficient nutrition

Question 24

best position for leg ulcers venous in origin

Answer 24

elevate lower extremities

Question 25

best prevention for skin breakdown of lower extremities post op

Answer 25

ensure clients heels are protected and supported

Question 26

assessments for chronic leg ulcers

Answer 26

-location and type of pain -bilateral comparison of peripheral pulses -comparison of temp in patients legs -identification of mobility limitations

Question 27

lymphangitis medication

Answer 27

an antibiotic

Question 28

best action by nurse for leg swelling and redness post op

Answer 28

inform health care provider of s/s of venous thromboembolism

Question 29

abdominal aortic aneurysm - assessment for impending rupture

Answer 29

sudden onset of severe back or abdominal pain

Question 30

what is systemic arteriovenous oxygen different that affect cardiovascular health and tissue oxygenation

Answer 30

the amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood

Question 31

on what physiologic variables does adequate blood flow depend

Answer 31

-efficiency of heart as a pump -adequacy of circulating blood volume -patency and responsiveness of the blood vessels

Question 32

peripheral artery disease - no pulse in left foot

Answer 32

use doppler ultrasound to identify the pulses

Question 33

for which client would assessment of ankle brachial index be most clearly warranted

Answer 33

a client with poorly controlled type 1 diabetes who is a smoker

Question 34

nursing plan to prevent occurrence of future venous ulcers

Answer 34

high protein diet that is rich in vitamins

Question 35

digital gangrene - history of what health problem

Answer 35

arterial insufficiency

Question 36

venous disease - what test

Answer 36

duplex ultrasonography

Question 37

peripheral arterial occlusive disease - assessment finding

Answer 37

unequal peripheral pulses between both extremities

Question 38

peripheral artery disease - history of smoking, alcohol, no exercise - priority education

Answer 38

the nicotine in cigarettes is a powerful vasoconstrictor and may cause or aggravate pad

Question 39

assessment of venous ulcer in area of lateral malleolus and unresponsive to treatment

Answer 39

heavy exudate