Lewis Chapter 40: Vascular Disorders

Question 1

A 50-year-old woman weighs 95 kg and has a history of tobacco use, high blood pressure, high sodium intake, and sedentary lifestyle. When an individualized care plan is developed for this client, which of the following risk factors related to PAD would the nurse determine need to be modified?

a. Salt intake

b. Sedentary lifestyle

c. Tobacco use

d. Excess weight

Answer 1

C.

Question 2

When teaching a patient about rest pain and PAD, what should the nurse explain as the cause of the pain?

a. Vasospasm of cutaneous arteries in the feet

b. Increase in retrograde venous perfusion of the lower legs

c. Decrease in arterial blood flow to the nerves of the feet

d. Decrease in arterial blood flow to the leg muscles during exercise

Answer 2

C.

Question 3

A client with infective endocarditis develops sudden left leg pain with pallor, paresthesia, and a loss of peripheral pulses. What should the nurse’s initial action be?

a. Elevate the leg to promote venous return.

b. Start anticoagulant therapy with IV heparin.

c. Notify the health care provider of the change in perfusion.

d. Position the patient in reverse Trendelenburg position to promote perfusion.

Answer 3

C.

Question 4

Which clinical manifestations are seen in clients with both Buerger’s disease and clients with Raynaud’s phenomenon? (Select all that apply.)

a. Intermittent low-grade fevers

b. Sensitivity to cold temperatures

c. Gangrenous ulcers on fingertips

d. Colour changes of fingers and toes

e. Episodes of superficial vein thrombosis

Answer 4

B, C, D.

Question 5

A client is admitted to the hospital with a diagnosis of abdominal aortic aneurysm. Which signs and symptoms would suggest that his aneurysm has ruptured?

a. Sudden shortness of breath and hemoptysis

b. Sudden, severe low back pain and bruising along his flank

c. Gradually increasing substernal chest pain and diaphoresis

d. Sudden, patchy blue mottling on feet and toes and rest pain

Answer 5

B.

Question 6

Which of the following are priority nursing measures 8 hours after an abdominal aortic aneurysm repair?

a. Assessment of cranial nerves and mental status

b. Administration of IV heparin and monitoring of aPTT

c. Administration of IV fluids and monitoring of kidney function

d. Elevation of the legs and application of graduated compression stockings

Answer 6

C.

Question 7

What is the first priority of interprofessional care of a client with a suspected acute aortic dissection?

a. Reduce anxiety.

b. Control blood pressure.

c. Monitor for chest pain.

d. Increase myocardial contractility.

Answer 7

B.

Question 8

Which of the following clients has the highest risk for venous thromboembolism (VTE)?

a. A 62-year-old man with spider veins who is having arthroscopic knee surgery

b. A 32-year-old woman who smokes, takes oral contraceptives, and is planning a trip to Europe

c. A 26-year-old woman who is 3 days postpartum and received maintenance IV fluids for 12 hours during her labour

d. An active 72-year-old man at home recovering from transurethral resection of the prostate for benign prostatic hyperplasia

Answer 8

B.

Question 9

Which clinical findings should the nurse expect in a person with an acute lower extremity VTE? (Select all that apply.)

a. Pallor and coolness of foot and calf

b. Mild to moderate calf pain and tenderness

c. Grossly diminished or absent pedal pulses

d. Unilateral edema and induration of the thigh

e. Palpable cord along a superficial varicose vein

Answer 9

B, D.

Question 10

Which of the following is a key teaching instruction for the client who is receiving anticoagulant therapy?

a. Monitor for and report any signs of bleeding.

b. Do not take acetaminophen (Tylenol) for a headache.

c. Decrease your dietary intake of foods containing vitamin K.

d. Arrange to have blood drawn routinely to check medication levels.

Answer 10

A.

Question 11

The nurse is planning care and teaching for a patient with venous leg ulcers. Which is the most important client action in healing and control of this condition?

a. Follow activity guidelines.

b. Using moist environment dressings.

c. Taking horse chestnut seed extract daily.

d. Apply graduated compression stockings.

Answer 11

D.

Question 12

The nurse is caring for a patient with a diagnosis of deep venous thrombosis (DVT). The patient has an order to receive enoxaparin 30 mg subcutaneously. Which of the following injection sites should the nurse use to administer this medication safely?

A. Buttock, upper outer quadrant
B. Abdomen, anterior-lateral aspect
C. Back of the arm, 5 cm away from a mole
D. Anterolateral thigh, with no scar tissue nearby

Answer 12

B. Enoxaparin (Lovenox) is a low-molecular-weight heparin (LMWH) that is given as a subcutaneous injection. The preferred injection site for this medication is the right and left anterolateral abdominal wall. All subcutaneous injections should be given away from scars, lesions, or moles.

Question 13

The nurse is preparing to administer a scheduled dose of subcutaneous heparin sodium to a patient. Which of the following should the nurse do to ensure that the medication is administered correctly?

A. Remove the air bubble in the prefilled syringe
B. Aspirate before injection to prevent intravenous administration
C. Rub the injection site after administration to enhance absorption
D. Pinch the skin between the thumb and forefinger before inserting the needle

Answer 13

D. The nurse should gather together or “bunch up” the skin between the thumb and the forefinger before inserting the needle into the subcutaneous tissue but release before removing the needle. The nurse should neither aspirate nor rub the site after injection.

Question 14

The nurse is admitting a preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin on a daily basis. Based on this history and the patient’s admission diagnosis, the nurse should prepare to administer which of the following medications?

A. Vitamin K
B. Vitamin B12
C. Heparin sodium
D. Protamine sulphate

Answer 14

A. Warfarin is an anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin.

Question 15

The nurse is caring for a patient who has been receiving warfarin as treatment for atrial fibrillation. Because warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which of the following complications early in the postoperative period?

A. Decreased cardiac output
B. Increased blood pressure
C. Cerebral or pulmonary emboli
D. Excessive bleeding from incision or IV sites

Answer 15

C. Warfarin is an anticoagulant that is used to prevent thrombi from forming on the walls of the atria during atrial fibrillation. Once the medication is terminated, thrombi could again form. If one or more detach from the atrial wall, they could travel as cerebral emboli from the left atrium, or pulmonary emboli from the right atrium.

Question 16

The nurse is reviewing the laboratory test results for a patient whose warfarin therapy was terminated during the preoperative period. The nurse concludes that the patient is in the most stable condition for surgery after noting which of the following international normalized ratio (INR) results?

A. 2.7
B. 1.0
C. 3.4
D. 1.8

Answer 16

B. The therapeutic range for international normalized ratio (INR) results is 2.0–3.0 for many clinical diagnoses and 0.75–1.25 is the normal value with no clinical diagnoses. The larger the number, the greater the amount of anticoagulation. For this reason, the safest value before surgery is 1.0, meaning that the anticoagulation has been reversed.

Question 17

Which of the following assessment findings would indicate that a patient is not receiving beneficial effects from the administration of enoxaparin?

A. Generalized weakness and fatigue
B. Crackles bilaterally in the lung bases
C. Pain and swelling in the lower extremity
D. Abdominal pain with decreased bowel sounds

Answer 17

C. Enoxaparin is a low-molecular-weight heparin (LMWH) used to prevent the development of deep vein thromboses (DVTs) in the postoperative period. Pain and swelling in the lower extremity can indicate development of a DVT and therefore may signal ineffective medication therapy.

Question 18

The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT). The patient now needs to undergo surgery for appendicitis. The nurse is reviewing the laboratory results for this patient before administering an ordered dose of vitamin K. The nurse determines that the medication is both safe to give and is most needed when the international normalized ratio (INR) is which of the following values?

A. 2.2
B. 1.0
C. 1.6
D. 1.2

Answer 18

A. Vitamin K is the antidote to warfarin which the patient has most likely been taking until admission for treatment of DVT. Warfarin is an anticoagulant that impairs the ability of the blood to clot. Therefore it is necessary to give vitamin K before surgery to reduce the risk of hemorrhage. The largest value of the INR indicates the greatest impairment of clotting ability, making 2.2 the correct selection.

Question 19

A postoperative patient asks the nurse why the physician ordered daily administration of enoxaparin. Which of the following responses by the nurse is best?

A. “This medication will help prevent breathing problems after surgery, such as pneumonia.”
B. “This medication will help lower your blood pressure to a safer level, which is very important after surgery.”
C. “This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal.”
D. “This medication is a narcotic pain medication that will help take away any muscle aches caused by positioning on the operating room table.”

Answer 19

C. Enoxaparin (Lovenox) is an anticoagulant used to prevent deep vein thromboses (DVTs) postoperatively. All other explanations or choices do not describe the action or purpose of enoxaparin.

Question 20

The nurse is caring for a preoperative patient who has a prescription for subcutaneous vitamin K. The nurse should verify that which of the following laboratory studies is abnormal before administering the dose?

A. Hematocrit (Hct)
B. Hemoglobin (Hb)
C. Prothrombin time (PT)
D. Partial thromboplastin time (PTT)

Answer 20

C. Vitamin K counteracts hypoprothrombinemia and/or reverses the effects of warfarin and thus decreases the risk of bleeding. High values for either the prothrombin time (PT) or the international normalized ratio (INR) demonstrate the need for this medication.

Question 21

The nurse is caring for a newly admitted patient with vascular insufficiency. The patient has a new order for enoxaparin 30 mg subcutaneously. Which of the following actions should the nurse do to correctly administer this medication?

A. Spread the skin before inserting the needle
B. Leave the air bubble in the prefilled syringe
C. Use the back of the arm as the preferred site
D. Sit the patient at a 30-degree angle before administration

Answer 21

B. The nurse should not expel the air bubble from the prefilled syringe because it should be injected to clear the needle of medication and avoid leaving medication in the needle track in the tissue.

Question 22

Which of the following interventions in the care of a patient with a diagnosis of chronic venous insufficiency (CVI) is priority?

A. Application of topical antibiotics to venous ulcers
B. Maintaining the patient’s legs in a dependent position
C. Administration of oral and subcutaneous anticoagulants (or both)
D. Teaching the patient the correct use of compression stockings

Answer 22

D. Chronic venous insufficiency (CVI) requires conscientious and consistent application of compression stockings. Anticoagulants are not necessarily indicated and antibiotics, if required, are typically oral or IV, not topical. The patient should avoid prolonged positioning with the limb in a dependent position.

Question 23

A patient with varicose veins has been prescribed compression stockings. Which of the following statements should be included when teaching the patient about compression stockings?

A. “As much as possible, try to keep your stockings on 24 hours a day.”
B. “While you’re still lying in bed in the morning, put on your stockings.”
C. “Dangle your feet at your bedside for 5 minutes before putting on your stockings.”
D. “Your stockings will be most effective if you can remove them for a few minutes several times a day.”

Answer 23

B. The patient with varicose veins should apply stockings in bed, before rising in the morning. Stockings should not be worn continuously but they should not be removed several times daily. Dangling at the bedside prior to application is likely to decrease their effectiveness.

Question 24

The nurse is assessing a patient’s peripheral intravenous site and notes that phlebitis has developed over the past several hours. Which of the following actions should the nurse implement first?

A. Remove the patient’s IV catheter
B. Apply an ice pack to the affected area
C. Decrease the IV rate to 20–30 mL/hour
D. Administer prophylactic anticoagulants

Answer 24

A. The priority intervention for superficial phlebitis is removal of the offending IV catheter; decreasing the IV rate is insufficient. Anticoagulants are not normally required, and warm, moist heat is often therapeutic.

Question 25

Which assessment finding is characteristic of a patient in the early stages of peripheral artery disease (PAD)?

A. Pain with ambulation

B. Bounding pedal pulses

C. Redness in the foot while sitting in a chair

D. Rest pain in the legs lasting more than 2 weeks

Answer 25

A. Pain with ambulation

Intermittent claudication is a classic symptom of PAD. This ischemic muscle pain is caused by exercise, resolves within 10 minutes or less with rest, and is reproducible. The ischemic pain is a result of the buildup of lactic acid from anaerobic metabolism. Once the patient stops exercising, the lactic acid is cleared and the pain subsides.

Question 26

Which assessment finding supports the diagnosis of peripheral artery disease (PAD)?

A. Body mass index (BMI) of 32

B. Blood pressure (BP) of 147/88 mm Hg

C. Ankle-brachial index (ABI) of 0.87

D. Fasting blood glucose level 7.2 mmol/L

Answer 26

C. Ankle-brachial index (ABI) of 0.87

An ABI of 0.87 would support the diagnosis of PAD. The ABI is calculated by dividing the ankle systolic BPs by the higher of the left and right brachial systolic BPs. Any ABI under 0.95 classifies as PAD. A normal ABI is 1.00 to 1.40; mild PAD occurs with an ABI of 0.95 of 0.71.

Question 27

Which assessment finding would the nurse expect of a patient with peripheral artery disease (PAD)?

A. Loss of hair on the legs and feet

B. Capillary refill of less than 3 seconds

C. Calf pain that is relieved with exercise

D. A warm sensation in the legs and feet

Answer 27

A. Loss of hair on the legs and feet

Patients with PAD have loss of hair on the legs and feet; thick toenails; pallor with elevation; dependent rubour; thin, cool, shiny skin with muscle atrophy; skin breakdown and arterial ulcers, especially over bony areas; and gangrene.

Question 28

Which assessment finding could indicate graft failure following a femoral–popliteal bypass graft?

A. Ankle-brachial index measurements are higher than baseline.

B. The patient has numbness and tingling in the affected extremity.

C. The patient complains of pain in the affected extremity.

D. Edema is present in the affected extremity.

Answer 28

B. The patient has numbness and tingling in the affected extremity.

Occlusion of a femoral–popliteal bypass graft or stent is manifested by numbness, tingling, or a cold extremity and should be reported to the health care provider immediately.

Question 29

Which body part is the most common location for arterial ulcers?

A. Posterior aspect of the fingers and hands

B. Upper and medial bilateral thighs

C. Plantar aspect of the bilateral feet

D. Lower-extremity bony prominences

Answer 29

D. Lower-extremity bony prominences

Arterial (ischemic) ulcers most often occur over bony prominences on the toes, feet, and lower legs. The nurse would educate the patient to assess these areas daily for changes.

Question 30

Which patient statement would cause the nurse to suspect peripheral artery disease (PAD)?

A. “When my legs are sore, I elevate them on several pillows. Putting them up in the air seems to help with the pain I have.”

B. “My feet have been pale in the morning, but by the end of the day are bright red. I have been experiencing hair loss on my legs.”

C. “Throughout the night, I experience cramping in both of my legs. But once I go for a morning walk, they feel much better.”

D. “I have noticed my legs are swollen by the end of the day. I elevate my feet at night and then the swelling is down by the next morning.”

Answer 30

B. “My feet have been pale in the morning, but by the end of the day are bright red. I have been experiencing hair loss on my legs.”

In PAD, skin becomes thin, shiny, and taut, and hair loss occurs on the lower legs. Pallor (blanching of the foot) develops in response to leg elevation (elevation pallor). Conversely, reactive hyperemia (redness of the foot) develops when the limb is in a dependent position (dependent rubour).

Question 31

Which response by the nurse is best for a patient with peripheral artery disease (PAD) and intermittent claudication who asks about an exercise program?

A. “A home exercise program is more beneficial to PAD patients than a supervised program. Let’s talk about how to warm up prior to your physical activity.”

B. “Walking is the recommended exercise to help decrease leg pain. You should exercise for a maximum of 20 minutes daily.”

C. “You should talk to the health care provider about this. Exercise programs are not commonly recommended to patients with PAD because of the risk for complications.”

D. “Supervised exercise programs are preferred. Walking is most effective, and exercise should be performed at least three times per week.”

Answer 31

D. “Supervised exercise programs are preferred. Walking is most effective, and exercise should be performed at least three times per week.”

Exercise should be performed for 30 to 60 minutes/day, 3 to 5 days/week, for a minimum of 3 months. Walking is the most effective exercise for PAD clients. Supervised use of a treadmill improves walking ability and quality of life in patients with PAD.

Question 32

Which information would the nurse provide to the preoperative patient scheduled for an endarterectomy who asks what occurs during the surgery?

A. “The affected extremity is removed, starting from the area slightly above the blocked artery.”

B. “The affected artery is opened, then the blocking plaque is removed.”

C. “The affected artery is bypassed by detouring blood around the lesion, using your saphenous vein.”

D. “The affected artery is opened, blocking plaque is removed, and a patch is sewn in to widen the lumen.”

Answer 32

B. “The affected artery is opened, then the blocking plaque is removed.”

Various surgical approaches can be used to improve blood flow beyond a blocked artery. Endarterectomy involves opening the artery and removing the obstructing plaque.

Question 33

Which patient statement would indicate an understanding of peripheral artery disease (PAD) and appropriate goals?

A. “I will decrease my use of cigarettes gradually.”

B. “I will reduce my sodium intake to 4 g/day.”

C. “I will inspect my feet every week for skin breakdown and ulcers.”

D. “I will exercise to increase my endurance, which will help relieve my leg pain.”

Answer 33

D. “I will exercise to increase my endurance, which will help relieve my leg pain.”

Regular exercise to increase endurance and relieve leg pain is an appropriate goal for a patient with PAD. Other goals include adequate tissue perfusion; intact, healthy skin on the extremities; and increased knowledge of disease and a treatment plan.

Question 34

Which assessment finding would cause immediate concern for the nurse providing care for a patient following embolectomy?

A. Edema of the affected extremity

B. Capillary refill of 3 seconds of the affected extremity

C. Pale skin on the bilateral lower extremities with pulses present

D. Pedal pulse undetected on the affected extremity

Answer 34

D. Pedal pulse undetected on the affected extremity

Loss of palpable pulses or a change in the Doppler sound over a pulse requires immediate notification of the health care provider and prompt intervention. This finding indicates that the patient is not receiving adequate blood supply, if any, to the extremity.

Question 35

Antiplatelet therapy, Exercise therapy, and Nutritional therapy are used for management of?

Answer 35

Peripheral Arterial Disease

Question 36

Which assessment finding is characteristic of a patient with a deep vein thrombosis (DVT)?

A. Generalized weakness and fatigue

B. Crackles bilaterally in the lung bases

C. Pain and swelling in a lower extremity

D. Abdominal pain with decreased bowel sounds

Answer 36

C. Pain and swelling in a lower extremity

Clinical manifestations of a DVT may include unilateral leg edema, pain, tenderness on palpation, dilated superficial veins, a sense of fullness in the thigh or calf, paresthesia, warm skin (typically warmer than the surrounding skin), erythema, and occasionally a systemic temperature elevation greater than 38°C.

Question 37

Which patient statement about anticoagulant therapy indicates to the nurse that further education is needed?

A. “I will take this medication so that the clot in my body dissolves.”

B. “I should notify my health care provider right away if I notice any unusual bruising.”

C. “This medication helps prevent the clot from spreading throughout my body.”

D. “Some anticoagulant medications need blood monitoring; I will check with my health care provider on how often I should follow up.”

Answer 37

A. “I will take this medication so that the clot in my body dissolves.”

Anticoagulants do not dissolve clots; they prevent more clots from forming. Clot lysis begins naturally through the body’s intrinsic fibrinolytic system.

Question 38

Which information would the nurse include in the discharge teaching plan for a patient with venous thromboembolism who is prescribed warfarin?

A. “Avoid contact sports and high-risk activities.”

B. “No routine laboratory monitoring is needed.”

C. “Increase your daily intake of dark, leafy vegetables.”

D. “Continue to use garlic as a dietary supplement.”

Answer 38

A. “Avoid contact sports and high-risk activities.”

Teaching for a patient prescribed warfarin includes avoiding any trauma or injury that might cause bleeding, such as contact sports.

Question 39

Which laboratory finding would be most concerning to the nurse caring for a patient with shortness of breath?

A. D-dimer of 441 ng/mL

B. White blood cell (WBC) count of 7800 cells/μL

C. Troponin of less than 0.01 ng/mL

D. Brain natriuretic peptide (BNP) of 10 pg/mL

Answer 39

A. D-dimer of 441 ng/mL

This D-dimer level would be most concerning because an elevated D-dimer can aid in the diagnosis of suspected pulmonary embolism (PE), and shortness of a breath is a classic manifestation of PE. Further assessment is needed for this patient immediately.

Question 40

Which statement would cause the nurse to provide further teaching about warfarin to a patient with a subtherapeutic international nationalized ratio (INR) level?

A. “My family helped me declutter my house so that I am less likely to trip.”

B. “I have been drinking a lot of water so that I do not become dehydrated.”

C. “Wearing my graduated compression stockings is still important even though I am on warfarin.”

D. “Since my leg venous thromboembolism, I have been trying to be healthier by eating more fruits and salads.”

Answer 40

D. “Since my leg venous thromboembolism, I have been trying to be healthier by eating more fruits and salads.”

Vitamin K, found often in green, leafy vegetables, decreases the effectiveness of warfarin. If the patient has suddenly increased their vitamin K intake, INR levels will decrease. The patient should maintain their vitamin K intake at a constant level, not increase or decrease it.

Question 41

Which patient is at the highest risk of developing varicose veins?

A. A male patient with arthritis

B. A male patient who is a professional cyclist

C. A female patient who works as a salon stylist

D. A female patient who was successful in a weight-loss program

Answer 41

C. A female patient who works as a salon stylist

This patient is at highest risk of developing varicose veins. This patient’s risk factors include her gender and prolonged standing.

Question 42

Which response by the nurse is best when a pregnant patient with newly diagnosed varicose veins asks how to prevent more varicose veins from developing?

A. “Be sure to rest often in a sitting position.”

B. “The varicose veins will disappear after you have given birth.”

C. “Wear graduated compression stockings and frequently elevate your legs.”

D. “These will have to be removed during a surgical procedure to prevent further spread.”

Answer 42

C. “Wear graduated compression stockings and frequently elevate your legs.”

Prevention and conservative treatment of varicose veins involves rest with limb elevation, graduated compression stockings, leg-strengthening exercises (such as walking), and weight loss, if indicated. A conservative approach is best for pregnant women.

Question 43

Which patient is at greatest risk for developing a venous ulcer?

A. A patient with elevated lipid levels

B. A patient with intermittent claudication

C. A patient with uncontrolled hypertension

D. A patient with uncontrolled varicose veins

Answer 43

D. A patient with uncontrolled varicose veins

Both long-standing primary varicose veins and post-thrombotic syndrome can progress to chronic venous insufficiency and venous ulcers.

Question 44

Which description is associated with venous leg ulcers?

A. Common in younger men

B. Life threatening

C. Unsightly but painless

D. Impairs quality of life

Answer 44

D. Impairs quality of life

Although venous leg ulcers are not life-threatening diseases, they are painful and debilitating and impair quality of life. They are a common problem in older persons.

Question 45

Which action is best for the nurse to take for a patient with a venous ulcer who states that their affected leg has been itching?

A. Obtaining an order for a topical steroid cream as needed

B. Assisting the patient in putting on compression stockings

C. Applying a fragrance-free moisturizer and instructing the patient to do this at home daily

D. Washing the leg multiple times daily with warm water and antimicrobial soap

Answer 45

C. Applying a fragrance-free moisturizer and instructing the patient to do this at home daily

Patients with chronic venous insufficiency often have dry, flaky, itchy skin because of eczema. Daily moisturizing decreases itching and prevents cracking of the skin.

Question 46

Which intervention should the nurse implement first when phlebitis has developed at the peripheral intravenous site?

A. Removing the patient’s intravenous (IV) catheter

B. Applying an ice pack to the affected area

C. Decreasing the IV rate to 20 to 30 mL/hour

D. Administering prophylactic anticoagulants

Answer 46

A. Removing the patient’s intravenous (IV) catheter

The priority intervention for superficial phlebitis is removal of the offending IV catheter. Warm, moist heat is often therapeutic.

Question 47

Which action would the nurse anticipate for a patient scheduled for emergency surgery who is receiving heparin intravenously for a lower-extremity venous thromboembolism?

A. Administering intravenous protamine

B. Administering intramuscular vitamin K

C. Monitoring the international nationalized ratio (INR) level

D. Communicating with the perioperative nurse to monitor for bleeding

Answer 47

A. Administering intravenous protamine

Protamine is the reversal agent of heparin and should be administered as ordered to prepare the patient for surgery. If the activated partial thromboplastin time level remains high during surgery, the patient is at risk for hemorrhage.

Question 48

Which response by the nurse is best when the patient with venous thromboembolism (VTE) states that they are “too tired to attend physical therapy today”?

A. “You must participate in physical therapy because the health care provider ordered it. I will help you through your session today.”

B. “Let’s discuss times for you to rest. It is important to engage in early activity because it will help decrease the swelling and pain in your leg.”

C. “I will call the health care provider to see if the physical therapy order can be discontinued. It is more important that you get adequate rest.”

D. “It is okay if you need to rest today, but you must wear your compression stockings to decrease swelling. Tomorrow you should participate in the physical therapy session.”

Answer 48

B.“Let’s discuss times for you to rest. It is important to engage in early activity because it will help decrease the swelling and pain in your leg.”

The patient should be encouraged to participate in physical therapy as ordered because early ambulation after VTE results in a more rapid decrease in edema and limb pain. However, the patient’s concern about fatigue should also be addressed.

Question 49

Which action is a priority by the home health nurse caring for a patient on anticoagulation therapy with a history of venous thromboembolism (VTE)?

A. Reducing fall risk factors by removing throw rugs

B. Repositioning the patient to prevent skin breakdown

C. Encouraging rest for long periods between activities

D. Educating the patient on the importance of increasing their intake of green, leafy vegetables

Answer 49

A. Reducing fall risk factors by removing throw rugs

Patients on anticoagulation therapy are at increased risk for bleeding and hemorrhage. Falls may cause extreme injury and bleeding, so a home environment assessment should be completed to remove items that patients may trip on.

Question 50

Which patient with a history of varicose veins has the highest risk of recurrence?

A. A patient who is a server in a restaurant

B. A patient who continues to wear compression stockings

C. A patient who uses pillows under the legs while sleeping

D. A patient who is an editor and sits at a desk 8 hours a day

Answer 50

D. A patient who is an editor and sits at a desk 8 hours a day

This patient is at higher risk for recurrence of varicose veins. The nurse should stress the importance of periodically positioning the legs above heart level, which will help decrease edema and the reoccurrence of varicose veins. Patients with a job that requires long periods of sitting need to frequently flex and extend their hips, legs, and ankles and change positions.

Question 51

Which statement by a patient who just received sclerotherapy for varicose veins indicates that further education is needed on postsclerotherapy care?

A. “I should elevate my legs to decrease swelling and the risk of clots.”

B. “I will monitor my leg for signs of infection, such as redness, tenderness, or drainage.”

C. “I am excited to leave for my trip tomorrow because I can finally relax without leg pain.”

D. “I will be sure to always wear my graduated compression stockings to prevent clots from developing.”

Answer 51

C.“I am excited to leave for my trip tomorrow because I can finally relax without leg pain.”

This patient response should prompt the nurse to further assess the patient’s understanding of sclerotherapy. Patients should not travel long distances during the first week after sclerotherapy to minimize the risk for a venous thromboembolism.

Question 52

Which meal selection options would the nurse provide the patient that will best promote venous ulcer wound healing?

A. A cheese sandwich and tomato soup

B. Banana bread and wheat toast with jam

C. A chicken and bean taco and salad with orange slices on the side

D. Meatless spaghetti with buttered bread and a bowl of steamed broccoli

Answer 52

C.A chicken and bean taco and salad with orange slices on the side

Foods high in protein (e.g., meat, beans, cheese, and tofu), vitamin A (green, leafy vegetables), vitamin C (citrus fruits, tomatoes, and cantaloupe), and zinc (meat and seafood) are most important for healing.

Question 53

Which response by the nurse is appropriate when a patient with a venous ulcer asks why they are not on antibiotics?

A. “I will contact the health care provider to speak to you about this.”

B. “Usually, a topical antibiotic is ordered for the ulcer; I will call the provider for an order.”

C. “The ulcer has no signs of acute infection, so antibiotics would not aid in the healing process.”

D. “Antibiotics are not recommended for this type of ulcer; to promote healing, I will cover it with a dry, sterile dressing.”

Answer 53

C.“The ulcer has no signs of acute infection, so antibiotics would not aid in the healing process.”

Venous leg ulcers are colonized by bacteria, but routine use of antibiotics is not indicated unless acute clinical signs of infection are present.

Question 54

Which finding would the nurse expect when assessing a patient with superficial vein thrombosis?

A. Appearance of the vein as a palpable cord

B. Tenderness to palpation over the involved vein

C. Presence of edema with pain

D. Induration of the overlying muscle

Answer 54

A. Appearance of the vein as a palpable cord

In superficial vein thrombosis, the vein appears as a palpable cord.
Tenderness to palpation over the involved vein is noted in venous thromboembolism, not superficial vein thrombosis.
Edema rarely occurs in superficial vein thrombosis.
Induration of overlying muscle is noted in venous thromboembolism, not superficial vein thrombosis.