Lewis Ch 37: Vascular Disorders

Question 1

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

Answer 1

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.

Question 2

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

Answer 2

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.

Question 3

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

Answer 3

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.

Question 4

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

Answer 4

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.

Question 5

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.

Answer 5

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

Question 6

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.

Answer 6

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.

Question 7

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.

Answer 7

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.

Question 8

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.”

Answer 8

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.

Question 9

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).

Answer 9

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.

Question 10

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.

Answer 10

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.

Question 11

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.

Answer 11

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.

Question 12

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.”

Answer 12

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.

Question 13

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.”

Answer 13

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.

Question 14

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.

Answer 14

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.

Question 15

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

Answer 15

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.

Question 16

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.”

Answer 16

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.

Question 17

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.

Answer 17

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.

Question 18

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.
N R I G B.C M
b. The nurse injects the drug into the abdominal subcutaneous tissue.
USNT O
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.

Answer 18

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.

Question 19

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

Answer 19

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.

Question 20

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.”

Answer 20

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.

Question 21

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.”

Answer 21

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.

Question 22

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.

Answer 22

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.

Question 23

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

Answer 23

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.

Question 24

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.

Answer 24

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.

Question 25

When caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding is most important for the nurse to communicate to the health care provider?

a. Presence of flatus
b. Hypoactive bowel sounds
c. Maroon-colored liquid stool
d. Abdominal pain with palpation

Answer 25

ANS: C
Loose, bloody (maroon-colored) stools at this time may indicate intestinal ischemia or infarction and should be reported immediately because the patient may need an emergency bowel resection. The other findings are normal on the first postoperative day after abdominal surgery.

Question 26

The nurse is caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty. Which action should the nurse perform first?

a. Obtain vital signs.
b. Teach wound care.
c. Assess pedal pulses.
d. Check the wound site.

Answer 26

ANS: A
Bleeding is a possible complication after catheterization of the femoral artery, so the nurse’s first action should be to assess for changes in vital signs that might indicate hemorrhage. The other actions are also appropriate but can be done after determining that bleeding is not occurring.

Question 27

A patient who is 2 days post femoral popliteal bypass graft to the right leg is being cared for on the vascular unit. Which action by a licensed practical/vocational nurse (LPN/VN) caring for the patient requires the registered nurse (RN) to intervene?

a. The LPN/VN tells the patient sit in a chair for 2 hours.
b. The LPN/VN gives the prescribed aspirin after breakfast.
c. The LPN/VN assists the patient to walk 40 ft in the hallway.
d. The LPN/VN places the patient in Fowler’s position for meals.

Answer 27

ANS: A
The patient should avoid sitting for long periods because of the increased stress on the suture line caused by leg edema and because of the risk for venous thromboembolism (VTE). The other actions by the LPN/LVN are appropriate.

Question 28

The nurse is developing a discharge teaching plan for a patient diagnosed with thromboangiitis obliterans (Buerger’s disease). Which expected outcome has the highest priority for this patient?

a. Cessation of all tobacco use
b. Control of serum lipid levels
c. Maintenance of appropriate weight
d. Demonstration of meticulous foot care

Answer 28

ANS: A
Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with Buerger’s disease. Other therapies have limited success in treatment of this disease.

Question 29

Which assessment finding for a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse?

a. Report of right calf pain
b. Erythema of right lower leg
c. New onset shortness of breath
d. Temperature of 100.4° F (38° C)

Answer 29

ANS: C
New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as O2 administration and notification of the health care provider. The other findings are typical of VTE.

Question 30

Which nursing intervention for a patient who had an open repair of an abdominal aortic aneurysm 2 days previously is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

a. Monitor the quality and presence of the pedal pulses
b. Teach the patient the signs of possible wound infection.
c. Check the lower extremities for strength and movement.
d. Help the patient to use a pillow to splint while coughing.

Answer 30

ANS: D
Assisting a patient who has already been taught how to cough is part of routine postoperative care and within the education and scope of practice for UAP. Patient teaching and assessment of essential postoperative functions such as circulation and movement should be done by RNs.

Question 31

The nurse is caring for a patient with a descending aortic dissection. Which assessment finding is most important to report to the health care provider?

a. Weak pedal pulses
b. Absent bowel sounds
c. Blood pressure of 138/88 mm Hg
d. 25 mL of urine output over the past hour

Answer 31

ANS: C
The blood pressure is typically kept at less than 120 mm Hg systolic to minimize extension of the dissection. The nurse will need to notify the health care provider so that -blockers or other antihypertensive drugs can be prescribed. The other findings are typical with aortic dissection and should also be reported but do not require immediate action.

Question 32

A patient is being evaluated for postthrombotic syndrome. Which assessment will the nurse perform?

a. Ask about leg pain with exercise.
b. Determine the ankle-brachial index.
c. Assess capillary refill in the patient’s toes.
d. Inspect for presence of lipodermatosclerosis.

Answer 32

ANS: D
Clinical signs of postthrombotic syndrome include lipodermatosclerosis. In this situation, the skin on the lower leg becomes scarred, and the leg becomes tapered like an “inverted bottle.” The other assessments would be done for patients with peripheral arterial disease.

Question 33

Which actions for a patient at risk for venous thromboembolism could the nurse delegate to
unlicensed assistive personnel (UAP)?
a. Monitor for any bleeding after anticoagulation therapy is started.
b. Tell the patient to call immediately if any shortness of breath occurs.
c. Apply sequential compression devices whenever the patient is in bed.
d. Ask the patient about use of any herbal medicines or dietary supplements.

Answer 33

ANS: C
UAP training includes the use of equipment that requires minimal nursing judgment, such as sequential compression devices. Patient assessment and teaching require more education and critical thinking and should be done by the registered nurse (RN).

Question 34

The nurse who works in the vascular clinic has several patients with venous insufficiency. Which patient should the nurse assign to an experienced licensed practical/vocational nurse (LPN/VN)?

a. Patient who has a history of venous thromboembolism and reports dyspnea.
b. Patient who has been reporting increased edema and skin changes in the legs.
c. Patient who needs wound care for a chronic venous stasis ulcer on the lower leg.
d. Patient who needs teaching about compression stockings for venous insufficiency.

Answer 34

ANS: C
LPN education and scope of practice includes wound care. The other patients, which require more complex assessments or education, should be managed by the RN.

Question 35

The nurse is admitting a patient newly diagnosed with peripheral artery disease who takes clopidogrel. Which admission order should the nurse question?

a. Cilostazol drug therapy
b. Omeprazole drug therapy
c. Use of treadmill for exercise
d. Exercise to the point of discomfort

Answer 35

ANS: B
Because the antiplatelet effect of clopidogrel is reduced when it is used with omeprazole, the nurse should clarify this order with the health care provider. The other interventions are appropriate for a patient with peripheral artery disease.