Exam 2: Vascular Problems

Question 1

What is the most classic cause of ischemic pain resulting from exercise in PAD that usually resolves in 10 mins?

Answer 1

Intermittent claudication

Question 2

What complications occur in PAD?

Answer 2

Amputation if ulcer continues not to heal and the gangrene spreads throughout the limb

Question 3

What if a pulse cannot be palpated in a patient who has PAD in the limb?

Answer 3

Use a doppler machine

Question 4

Interprofessional care of a patient with PAD includes?

Answer 4

• Gently cleansing the feet to help prevent further trauma
• Avoid soaking which could lead to maceration of the skin
• Keep skin dry

Question 5

What is a diagnosis for PAD?

Answer 5

Ineffective peripheral tissue perfusion related to deficient knowledge of contributing factors

Question 6

Which action should be taken first for a patient who arrived after having percutaneous transluminal balloon angioplasty?

Answer 6

Take the blood pressure and pulse rate FIRST (to obtain baseline vitals)

Question 7

A 55-year-old man weighs 115 kg and has a history of tobacco use, hypertension, and has a sedentary lifestyle. Which risk factor should the nurse treat first?

Answer 7

Tobacco use

Question 8

What are the goals for a patient undergoing surgery for an aneurysm? (3)

Answer 8

• normal tissue perfusion
• intact motor and sensory function
• no complications related to surgical repair

Question 9

A patient is recovering from an aneurysm repair. Which vital sign result would need immediate action?

Answer 9

Blood pressure of 196/100

Question 10

Nursing care includes what medications for venous thromboembolism? (2)

Answer 10

• Lovenox: started in acute care setting, works quickly

- Coumadin: used closer to discharge, takes longer to help with prevention of clots

Question 11

Anticoagulant therapy for VTE: therapeutic levels? control value levels for therapy to be effective?

Answer 11

Therapeutic levels: 45-76

Control value time: 1.5-2.0

Question 12

Considering therapeutic levels and control value levels, a patient can be? (3)

Answer 12

• Subtherapy: lower than the range at a risk for clotting, medication is not HIGH enough
• Therapy: within range
• Risk for hemorrhage: HIGHER than the therapeutic range

Question 13

Nursing diagnosis for VTE? (2)

Answer 13

• Bleeding related to anticoagulant therapy

- PE related to embolization of thrombus, dehydration, immobility

Question 14

The patient has an aptt result of 40. The control is 30. What is the patient’s control range?

Answer 14

45-60

Question 15

T/F: the patient has an aptt result of 65. The control range is 40-60. The patient is at risk for hemorrhage.

Answer 15

True