chapter 40 Flashcards
The nurse is discussing risk factor modification for a client who has a 4-cm abdominal
aortic aneurysm. The nurse should focus client teaching on which of the following risk
factors?
a. Male gender
b. Marfan syndrome
c. Abdominal trauma history
d. Uncontrolled hypertension
D
All of the factors contribute to the client’s risk, but only the hypertension can potentially
be modified to decrease the client’s risk for further expansion of the aneurysm.
The nurse is obtaining a health history from a client who has a 5-cm thoracic aortic
aneurysm that was discovered during a routine chest x-ray. Which of the following
symptoms should the nurse expect to assess in the client?
a. Back or lumbar pain
b. Difficulty 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 clients with abdominal
aortic aneurysms.
Several hours after an open surgical repair of an abdominal aortic aneurysm, the client
develops a urinary output of 20 mL/hour for 2 hours. Which of the following prescriptions
should the nurse anticipate?
a. An additional antibiotic
b. White blood cell (WBC) count
c. Decrease in IV infusion rate
d. Blood urea nitrogen (BUN) level
D
The decreased urine output suggests decreased renal perfusion, and monitoring of renal
function is needed. There is no indication that infection is a concern, so antibiotic therapy
and a WBC count are not needed. The IV rate may be increased because hypovolemia may
be contributing to the client’s decreased urinary output.
A client in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD).
Which of the following medication categories should the nurse plan to include when
providing client teaching about PAD management?
a. Statins
b. Vitamins
c. Thrombolytics
d. Anticoagulants
A
Current research indicates that statin use by clients with PAD improves multiple outcomes.
There is no research that supports the use of the other medication categories in PAD.
The nurse is caring for a client with chronic atrial fibrillation who develops sudden severe
pain, pulselessness, pallor, and coolness in the left leg. Which of the following actions
should the nurse implement first?
a. Elevate the left leg on a pillow.
b. Apply an elastic wrap to the leg.
c. Assist the client in gently exercising the leg.
d. Notify the health care provider.
D
The client’s history and clinical manifestations are consistent with acute arterial occlusion.
Clinical manifestations of acute arterial ischemia include the “six Ps”: pain, pallor,
paralysis, pulselessness, paresthesia, and poikilothermia (adaptation of the limb to the
environmental temperature, most often cool). Without immediate intervention, ischemia
may progress quickly to tissue necrosis and gangrene within a few hours. If the nurse
detects these signs, the nurse should immediately notify the health care provider. 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 client 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.” Which of the following actions should the nurse implement?
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 colour changes that occur in response to cold.
d. Assess for unilateral swelling, redness, and tenderness of either leg.
A
The nurse should assess for other clinical manifestations of peripheral arterial disease in a
client who describes intermittent claudication. Changes in skin colour 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 point to
venous thrombo-embolism (VTE).
The nurse is assessing a client who has chronic peripheral artery disease (PAD) of the legs
and an ulcer on the left great toe. Which of the following findings should the nurse expect?
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
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 providing teaching to a client with critical limb ischemia. Which of the
following client statements indicate further teaching is required?
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
Because the client has impaired circulation and sensation to the feet, the use of a heating
pad could lead to burns. The other client statements are correct and indicate that teaching
has been successful.
The nurse is providing teaching to a client with newly diagnosed Raynaud’s phenomenon
about how to manage the condition. Which of the following behaviours by the client
indicates that the teaching has been effective?
a. The client avoids the use of Aspirin and nonsteroidal anti-inflammatory drugs
(NSAIDs).
b. The client exercises indoors during the winter months.
c. The client places the hands in hot water when they turn pale.
d. The client takes pseudoephedrine for cold symptoms.
B
Clients should avoid temperature extremes by exercising indoors when it is cold. To avoid
burn injuries, the client 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 Aspirin and NSAIDs with Raynaud’s phenomenon.
The nurse notes bruising and discoloration of the right leg of a client that has just arrived
in the recovery unit from having vein ligation surgery. Which of the following
interventions is priority?
a. Place the client in the Trendelenburg position.
b. Contact the health care provider.
c. Elevate the bed at the knee and put pillows under the feet.
d. Elevate the legs 15 degrees to limit edema.
D
After vein ligation surgery, the legs should be elevated 15 degrees to limit edema. Placing
the client in the Trendelenburg position will lower the head below heart level, which is not
indicated for this client. Placing pillows under the calf or elevating the bed at the knee may
cause blood stasis at the calf level. Bruising and discoloration are expected after vein
ligation surgery so there is no need to contact the health care provider at this time.
The health care provider prescribes an infusion of argatroban and daily partial
thromboplastin time (PTT) testing for a client with venous thrombo-embolism (VTE).
Which of the following actions should the nurse include in the plan of care?
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
IM injections are avoided in clients receiving anticoagulation. A PTT of 50 seconds is
within the therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not
affected by VTE.
A client with a venous thrombo-embolism (VTE) is started on enoxaparin and warfarin.
The client asks the nurse why two medications are necessary. Which of the following
responses by the nurse is accurate?
a. “Administration of two anticoagulants reduces the risk for recurrent venous
thrombosis.”
b. “Enoxaparin will start to dissolve the clot, and warfarin will prevent any more
clots from occurring.”
c. “The enoxaparin will work immediately, but the warfarin 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
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.
The nurse has initiated discharge teaching for a client who is to be maintained on warfarin
following hospitalization for venous thrombo-embolism (VTE). Which of the following
client statements indicates that additional teaching is required?
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 warfarin.”
c. “I will need to have blood tests routinely to monitor the effects of the warfarin.”
d. “I will check with my health care provider before I begin or stop any medication.”
A
Clients taking warfarin are taught to follow a consistent diet with regard to foods that are
high in vitamin K, such as green, leafy vegetables. The other client statements are
accurate.
The nurse is caring for a client who had a sclerotherapy for treatment of superficial
varicose veins and is a service-counter worker. Which of the following information should
the nurse include when providing discharge teaching to the client?
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 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 to the client who
had just had sclerotherapy.
The nurse is providing teaching to a client with chronic venous insufficiency who has a
venous ulcer on the right lower leg. Which of the following topics should the nurse include
in the teaching plan?
a. Adequate carbohydrate intake
b. Prophylactic antibiotic therapy
c. Application of compression to the leg
d. Methods of keeping the wound area dry
C
Compression of the leg is essential to healing of venous ulcers in clients with chronic
venous insufficiency. High dietary intake of protein, rather than carbohydrates, is needed.
Prophylactic antibiotics are not routinely used for venous ulcers. Moist environment
dressings are used to hasten wound healing.
