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A nurse is developing a nursing care plan for a client with peripheral arterial
disease. Which of the following will be the priority nursing diagnosis? A.
Ineffective thermoregulation B. Ineffective self-health management C. Impaired
tissue integrity D. Ineffective peripheral tissue perfusion D.
Ineffective peripheral tissue perfusion
"A nurse is teaching a client who will soon be discharged with a prescription for
warfarin (Coumadin). Which statement should the nurse include in discharge
teaching? A. ""Eat more yogurt and broccoli."" B. ""This drug will dissolve any
clots you may still have."" C. ""Don't take aspirin while you're taking
warfarin."" D. ""If you miss a dose, double the next dose.""" "C. ""Don't
take aspirin while you're taking warfarin."""
Which term refers to a muscular, cramplike pain in the extremities consistently
reproduced with the same degree of exercise and relieved by rest? A. Aneurysm B.
Intermittent claudication C. Bruit D. Ischemia B. Intermittent
claudication Bruit - is a sound produced by turbulent blood flow through an
irregular, tortuous, stenotic, or dilated vesselAneurysm - is a localized sac or
dilation of an artery formed at a weak point in the vessel wall
Following abdominal surgery, which factor predisposes a client to deep vein
thrombosis? A. The client has been pregnant four times. B. The client is 5'9 tall
and weighs 128 lb (58 kg). C. The client will be immobile during and shortly after
surgery. D. The client usually walks 3 miles a day. C. The client will be
immobile during and shortly after surgery.
"A nurse is reviewing self-care measures for a client with peripheral vascular
disease. Which statement indicates proper self-care measures? A. ""I walk only to
the mailbox in my bare feet."" B. ""I have my wife look at the soles of my feet
each day."" C. ""I stopped smoking and use only chewing tobacco."" D. ""I like to
soak my feet in the hot tub every day.""" "B. ""I have my wife look at the
soles of my feet each day."""
The nurse teaches the client with peripheral vascular disease (PVD) to refrain from
smoking because nicotine causes? A. slows the heart rate. B. causes diuresis. C.
causes vasospasm. D. depresses the cough reflex. C. causes vasospasm.

A nurse is assessing a client's right lower leg, which is wrapped with an elastic
bandage. Which signs and symptoms suggest circulatory impairment? A. Redness, cool
skin temperature, and swelling B. Numbness, warm skin temperature, and redness C.
Numbness, cool skin temperature, and pallor D. Swelling, warm skin temperature,
and drainage C. Numbness, cool skin temperature, and pallor
The most important reason for a nurse to encourage a client with peripheral
vascular disease to initiate a walking program is that this form of exercise helps
how? A. reduces stress. B. decreases venous congestion. C. increases high-
density lipoprotein (HDL) level. D. aids in weight reduction. B. decreases
venous congestion Regular walking is the best way to decrease venous congestion
because using the leg muscles as a pump helps return blood to the heart. Regular
exercise also aids in stress reduction and weight reduction and increases the
formation of HDLs — which are all beneficial to a client with peripheral vascular
disease. However, these changes don't have as significant an effect on the client's
condition as decreasing venous congestion.
A client has been diagnosed with peripheral vascular disease of the lower
extremities. What site would the nurse use to assess circulation of the legs?
Temporal artery Radial artery Carotid artery D. Dorsalis pedis artery
D. Dorsalis pedis artery
"While the nurse is providing preoperative teaching for a client with peripheral
vascular disease who is to have a below-the-knee amputation, the client says, ""I
hate the idea of being an invalid after they cut off my leg."" The nurse's most
therapeutic response would be A. ""Tell me more about how you are feeling."" B.
""We will talk more about this after your surgery."" C. ""You are fortunate to
have a wife who can take care of you."" D. ""Focusing on using your one good leg
will make your recovery easier.""" "A. ""Tell me more about how you are
feeling."""
"A nurse is reviewing self-care measures for a client with peripheral vascular
disease. Which statement indicates proper self-care measures? A. ""I walk only to
the mailbox in my bare feet."" B. ""I like to soak my feet in the hot tub every
day."" C. ""I stopped smoking and use only chewing tobacco."" D. ""I have my wife
look at the soles of my feet each day.""" "D. ""I have my wife look at the
soles of my feet each day."""
"A nurse is providing discharge instructions to a client with peripheral vascular
disease that include stress-reduction techniques. The client asks the nurse, ""Why
is reducing stress so important?"" What is the nurse's best response? A.
""Reducing stress will help decrease the amount of medication you take for
peripheral vascular disease."" B. ""Stress reduction techniques are helpful because
stress stimulates the release of vasoconstricting catecholamines."" C. ""Stress
reduction techniques will distract you from focusing on claudication pain.""
D.""Reducing stress is helpful only because it will assist in smoking cessation."""
"B. ""Stress reduction techniques are helpful because stress stimulates
the release of vasoconstricting catecholamines."""
A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis
should receive highest priority at this time? A. Risk for injury related to edema
B. Ineffective peripheral tissue perfusion related to venous congestion C.
Impaired gas exchange related to increased blood flow D. Excess fluid volume
related to peripheral vascular disease B. Ineffective peripheral tissue
perfusion related to venous congestion
The client with peripheral vascular disease has been prescribed diltiazem. The
nurse should determine the effectiveness of this medication by assessing the client
for: A. relief of anxiety. B. sedation. C. vasodilation. D. vasoconstriction.
C. vasodilation.
A diabetic client with peripheral vascular disease is ordered to wear knee-high
elastic compression stockings continuously until discharge. Which of the following
would be the priority for this client after the stockings are applied? A. Elevate
the client's legs while out of bed. B. Teach the client isotonic leg exercises.
C. Remove elastic stockings once per day and observe lower extremities. D. Order a
second pair of stockings to be rotated each day. C. Remove elastic
stockings once per day and observe lower extremities.
When assessing an individual with peripheral vascular disease, which clinical
manifestation would indicate complete arterial obstruction in the lower left leg?
A. burning pain in the left calf B. numbness and tingling in the left leg C.
coldness of the left foot and ankle D. aching pain in the left calf C.
coldness of the left foot and ankle Coldness in the left foot and ankle is
consistent with complete arterial obstruction. Other expected findings would
include paralysis and pallor. Aching pain, a burning sensation, or numbness and
tingling are earlier signs of tissue hypoxia and ischemia and are commonly
associated within incomplete obstruction
A client with peripheral vascular disease has poor circulation. The nurse should
assess the client for changes in what? SATA A. fluid intake B. skin temperature
C. pain in extremity D. nail bed color E. nausea B. skin temperature C.
pain in extremity D. nail bed color
A client with no known history of peripheral vascular disease comes to the
emergency department complaining of sudden onset of lower leg pain. Inspection and
palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and
cadaverous left calf. While the physician determines the appropriate therapy, the
nurse should: A. place a heating pad around the affected calf. B. elevate the
affected leg as high as possible. C. keep the affected leg level or slightly
dependent. D. shave the affected leg in anticipation of surgery. C.
keep the affected leg level or slightly dependent.
A client has been diagnosed with PVD. What area of the body should the nurse focus
the assessment? A. The lower extremities B. Lung sounds C. Heart rate and rhythm
D. The abdominal area A. The lower extremities
Which of the following explains the influence of aging on the development of
peripheral vascular disease? A. Increased resistance. B. Decreased resistance.
C. Decreased viscosity. D. Increased viscosity. A. Increased resistance.
As people age, the accumulation of collagen in the intima of the blood vessels
results in the vessels' becoming stiff and less flexible. Consequently, there is an
increased resistance within the aging adult's circulatory system
Vasodilation or vasoconstriction produced by an external cause will interfere with
a nurse's accurate assessment of a client with peripheral vascular disease (PVD).
Therefore, the nurse should: A. match the room temperature to the client's body
temperature. B. keep the client warm. C. keep the client uncovered. D. maintain
room temperature at 78° F (25.6° C). B. keep the client warm.
A nurse cares for a client who is postoperative cholecystectomy. Which action by
the nurse is appropriate to help prevent the occurrence of venous stasis? A. Raise
the foot of the bed for an hour and then lower it. B. Massage lower extremities
vigorously every 6 hours. C. Assist in active range-of-motion exercise of the upper
body. D. Assist the client to walk as soon and as often as possible. D.
Assist the client to walk as soon and as often as possible.
Which of the following assessment findings is most congruent with chronic arterial
insufficiency? A. Brown pigmentation around a client's ankles and shins B.
Ulceration on the medial surface of the client's ankle C. Thickened and scarred
skin on the client's ankle D. Cool foot temperature and ulceration on the client's
great toe D. Cool foot temperature and ulceration on the client's great toe

Which of the following wounds is most likely attributable to neuropathy? A. A

painful wound in the client's shin, which is surrounded by apparently healthy skin
B. A moderately painful wound on the lateral aspect of the client's ankle C. A
painless wound on the sole of the client's foot, which is surrounded by calloused
skin D. A wound on a client's highly edematous ankle that is surrounded by
pigmented skin C. A painless wound on the sole of the client's foot, which
is surrounded by calloused skin
During a physical examination, the nurse detects warm skin and brown pigmentation
around an adult client's ankles. The nurse suspects that the client may be
experiencing A. venous insufficiency. B. arterial occlusive disease. C. venous
ulcers. D. ankle edema. A. venous insufficiency.
"The nurse is assessing the peripheral vascular system of an older adult client.
The client tells the nurse that her legs ""seem cold all the time and sometimes
feel tingly."" The nurse suspects that the client may be experiencing A. varicose
veins. B. intermittent claudication. C. edema. D. thrombophlebitis." B.
intermittent claudication.
A client has a brownish discoloration of the skin of both lower legs. What should
the nurse suspect is occurring with this client? A. atherosclerosis B. arterial
insufficiency C. venous insufficiency D. deep vein thrombosis C. venous
insufficiency
A client reports pain in the legs that begins with walking but is relieved by rest.
Which condition should the nurse assess the client for? A. Obstruction in the
femoral artery B. Peripheral vascular problems C. Diabetes mellitus D. Calcium
deficiency B. Peripheral vascular problems
While performing a routine check-up on an 81-year-old retired grain farmer in the
vascular surgery clinic, the nurse notes that he has a history of chronic arterial
insufficiency. Which of the following physical examination findings of the lower
extremities would be expected with this disease? A. Normal pulsation B. Normal
temperature C. Marked edema D. Thin, shiny, atrophic skin D. Thin, shiny,
atrophic skin
A nurse is working with a patient who has been confined to bed rest in the hospital
for the past 2 weeks. Which areas of the body are most likely to develop ulcers due
to arterial insufficiency? SATA - Tips of toes - Medial ankle - Toe webs - Heels -
Anterior tibial area - Toe webs - Heels - Tips of toes These spots are
where most pressure points of the body are localized
During the admission assessment, the nurse identifies the client has a history of
Raynaud's. What assessment finding would the nurse expect to find? A. Cold fingers
and hands B. Cool legs bilaterally C. Cool leg on one side D. Capillary refill less
than 2 seconds A. Cold fingers and hands
The nurse is planning care for a patient recovering from orthopedic surgery.
Interventions should be included to address which contributing factor to deep vein
thrombosis development? A. Immobility B. Obesity C. Smoking D. Hypertension
A. Immobility
A 57-year-old maintenance worker comes to the office for evaluation of pain in his
legs. He is a two-pack per day smoker since the age of 16, but he is otherwise
healthy. The nurse is concerned that the client may have peripheral vascular
disease. Which of the following is part of common or concerning symptoms for the
peripheral vascular system? A. Intermittent claudication B. Chest pressure with
exertion C. Shortness of breath D. Knee pain A. Intermittent claudication

A nurse receives an order to perform a compression test to assess the competence of

the valves in a client's varicose veins. Which action by the nurse demonstrates the
correct way to perform this test? A. Ask the client to sit on a chair for the
examination B. Firmly compress the lower portion of the varicose vein C. Place the
second hand 3 to 4 inches above the first hand D. Feel for a pulsation to the
fingers in the lower hand B. Firmly compress the lower portion of the
varicose vein
"A client diagnosed with intermittent claudication wonders why the nurse wants to
know where the client is experiencing cramping when walking. What would be the
nurse's best answer? A. ""The area of pain tells us what treatment will work best
for you."" B. ""The area of cramping indicates whether you may have numbness and
tingling also."" C. ""The area of pain can help us identify what risk factor is
predominant."" D. ""The area of cramping is close to the area of arterial
occlusion.""" "D. ""The area of cramping is close to the area of arterial
occlusion."""
A nurse has just inspected a standing client's legs for varicosities. The nurse
would now like to assess for suspected phlebitis. Which of the following should the
nurse do next? A. Have the client sit down B. Use a Doppler ultrasound device on
the client's leg C. Lightly palpate the client's leg veins for tenderness D.
Dorsiflex the client's foot and apply light pressure lateral to and along the side
of the extensor tendon of the big toe C. Lightly palpate the client's leg
veins for tenderness
What is a long-term complication of peripheral vascular disease? A. Metabolic
changes B. Thickened skin C. Amputation D. Diabetes mellitus C.
Amputation
When assessing the extremities of a client reporting leg cramping, the nurse notes
muscle atrophy. What does the nurse suspect is the cause? A. Peripheral arterial
disease B. Chronic lymphedema C. Venous insufficiency D. Arterial aneurysm
A. Peripheral arterial disease
A nurse experiences difficulty with palpation of the dorsalis pedis pulse in a
client with arterial insufficiency. What is an appropriate action by the nurse
based on this finding? A. Attempt to palpate the posterior tibial pulse. B. Assess
adequacy of blood flow using a Doppler device. C. Check the extremity for findings
of decreased blood flow. D. Obtain an order for ankle brachial index test to be
performed. B. Assess adequacy of blood flow using a Doppler device.
A 68-year-old retired truck driver comes to the office for evaluation of swelling
in his legs. He is a smoker and has been taking medications to control his
hypertension for the past 25 years. The nurse is concerned about the client's risk
for peripheral vascular disease. Which of the following tests is appropriate to
order to initially evaluate for this condition? A. Venogram B. CT scan of the
lower legs C. Ankle-brachial index (ABI) D. PET scan C. Ankle-brachial index
(ABI)
A nurse performs the Trendelenburg test for a client with varicose veins. Which
action should the nurse take when performing this test? A. Legs should be elevated
for 15 seconds B. Tourniquet should be put on before leg elevation C. Have the
client stand upright after tourniquet removal D. Ensure that the client's legs are
over the side of the bed A. Legs should be elevated for 15 seconds
The client complains of pain and numbness in his left lower leg. The nurse
identifies on assessment that the left leg is cool and gray in color. The nurse
suspects what? A. Deep vein thrombosis B. Arterial occlusion C. Pulmonary embolism
D. Venous thromboembolism B. Arterial occlusion
During the assessment, the nurse identifies warm thick skin that is reddish-blue.
The nurse also notes a painful ulcer at the ankle. The nurse suspects the client
may have what? A. Arterial insufficiency B. Venous insufficiency C. Intermittent
claudication D. Hypertrophic changes B. Venous insufficiency
When assessing the lymph system of an adult client, the nurse notes that the
epitrochlear nodes are nonpalpable. What does this indicate? a.Atherosclerosis
b.Normal finding c.Possible lymphoma d.No lymphedema b. Normal finding
Explanation: Normally, the epitrochlear nodes are not palpable. Normal palpable
nodes are 2 cm or less. Nonpalpable epitrochlear nodes are not an indication of
lymphoma or atherosclerosis. They are not related to lymphedema or its absence.

A hospitalized post-operative client exhibits edema, pain, erythema, and warmth in

the right calf area. What is the nurse's best action? a.Encourage early
ambulation. b.Assist the client to turn, cough, and deep breathe. c.Discontinue the
indwelling urinary catheter. d.Notify the healthcare provider. d. Notify
the healthcare provider. Explanation: The client is exhibiting signs of venous
thromboembolism. The healthcare provider should be notified immediately to prevent
further complications. This condition is a national client safety concern for
hospitalized clients. Early ambulation could dislodge a possible clot. Prevention
of pneumonia is encouraged by turning, coughing, and deep breathing. Signs of a
urinary tract infection include pain, increased white blood cells, and fever.

The nurse is caring for a client with venous ulcers on both legs. The client is
complaining of pain. What is the nurse's best action? a.Observe for gangrene
areas. b.Elevate the legs on pillows. c.Assess for diminished pulses. d.Lower the
legs below heart level. b. Elevate the legs on pillows. Explanation: Common
complaints of venous ulcer pain include: aching pain and feeling of heaviness which
is relieved with elevation of the legs. Relief for arterial ulcer pain is achieved
by dependently positioning the legs below the heart. Gangrene and decreased pulses
more commonly occur with arterial ulcers; assessing for these symptoms doesn't
address the client's pain.
A client visits the clinic and tells the nurse that she had a mastectomy 2 years
ago. The nurse should assess the client for... a.lymphedema. b.Raynaud disease.
c.poor peripheral pulses. d.bruits over the radial artery. a. lymphedema.
Explanation: Lymphedema results from blocked lymphatic circulation, which may be
caused by breast surgery. It usually affects one extremity, causing induration and
nonpitting edema.
Which pulse is located at approximately the inner third of the antecubital fossa
when the palm is held upward? a.Epitrochlear b.Radial c.Ulnar d.Brachial
d. Brachial Explanation: The brachial pulses are located at approximately
the inner third of the antecubital fossa when the palm is held up. It is not
usually necessary to palpate the ulnar pulse, which is difficult to locate. The
radial pulse site is used when assessing the pulse for vital signs. Epitrochlear is
not a term used to identify a pulse.
Which of the following assessment findings is most congruent with chronic arterial
insufficiency? a.Brown pigmentation around a client's ankles and shins
b.Ulceration on the medial surface of the client's ankle c.Thickened and scarred
skin on the client's ankle d.Cool foot temperature and ulceration on the client's
great toe d. Cool foot temperature and ulceration on the client's great toe
Explanation: Pigmentation, medial ankle ulceration, and thickened, scarred skin are
associated with venous insufficiency, while low temperature and toe ulceration are
more commonly found in cases of arterial insufficiency.
The nurse is providing care for a 61-year-old female smoker who is 30 kg overweight
and was diagnosed with type 2 diabetes several years prior. Which of the following
teaching points regarding the prevention of peripheral artery disease (PAD) is most
accurate? a.If you develop swelling in your ankles or feet, then you should seek
emergency care. b.Quitting smoking and keeping good control of your blood sugar
levels are important. c.It's critical that you come to get screening tests twice
annually. d.I'll show you how to check your pulses at your groin, knees and feet to
monitor your risk of PAD. b. Quitting smoking and keeping good control of
your blood sugar levels are important. Explanation: Smoking cessation and adequate
glycemic control should be prioritized when teaching this client. Ankle edema
should be assessed and followed up, but would not likely necessitate emergency
care. Clients are not normally taught self-assessment of pulses, and quitting
smoking and controlling blood glucose are more important than screening tests.

During the admission assessment, the nurse identifies the client has a history of
Raynaud's. What assessment finding would the nurse expect to find? a.Cold fingers
and hands b.Cool legs bilaterally c.Cool leg on one side d.Capillary refill less
than 2 seconds a. Cold fingers and hands Explanation: Raynaud's is
exhibited by cold fingers and hands. Cool extremities could be due to a cool room
or arterial insufficiency. A capillary refill of less than 2 seconds is normal.

A client presents to the health care clinic with a 3-week history of pain and
swelling of the right foot. A nurse inspects the foot and observes swelling and a
large ulcer on the heel. The client reports the right heel is very painful and he
has trouble walking. Which nursing diagnosis should the nurse confirm from these
data? a.Fear of Loss of Extremity b.Impaired Skin Integrity c.Risk for Skin
Breakdown d.Imbalanced Nutrition b. Impaired Skin Integrity Explanation:
This client demonstrates Impaired Skin Integrity as evidenced by the ulcer on his
heel. With the location and the presence of pain, this is most likely to be an
ulcer of arterial insufficiency. The client has not verbalized any fear at this
time. With the existing skin breakdown, he is not at risk because it is present.

A client presents to the health care clinic with reports of swelling, pain, and
coolness of the lower extremities. The nurse should recognize that which of these
lifestyle practices are risk factors for peripheral vascular disease? SATA -
Cigarette smoking - Regular exercise - Stress-reduction techniques - Low alcohol
intake - Previous use of hormones - High-fat diet - Cigarette smoking -
Previous use of hormones - High-fat diet Explanation: The risk factors for the
development of peripheral vascular disease include smoking, lack of exercise, high
stress, moderate to high alcohol intake, previous use of hormonal birth control
(females), and a high-fat diet.
The nurse is planning care for a client recovering from orthopedic surgery.
Interventions should be included to address which contributing factor to deep vein
thrombosis development? a.Immobility b.Obesity c.Smoking d.Hypertension
a. Immobility Explanation: Immobility can lead to blood stasis, which is a
contributing factor to the development of a deep vein thrombosis. Obesity is a risk
factor for the development of arterial and venous disease. Smoking is a risk factor
for arterial and venous disease and for the development of an abdominal aortic
aneurysm. Hypertension is a risk factor for arterial disease and abdominal aortic
aneurysm.
The client has a history of breast cancer with reconstructive surgery. The nurse
should assess the client for what potential complication? a.Lymphedema
b.Peripheral arterial disease c.Venous stasis d.Varicose veins a.
Lymphedema Explanation: Lymphedema can be a result of scarring injury, removal of
lymph nodes, radiation or chronic infection. Peripheral arterial disease is caused
by decreased arterial blood supply. Venous stasis is due to blood not moving which
puts the client at risk for varicose veins.
The major artery that supplies blood to the arm is the... a.radial artery. b.ulnar
artery. c.posterior artery. d.brachial artery. d. brachial artery.
Explanation: The brachial artery is the major artery that supplies the arm.
Goals, although not specific for peripheral vascular disease, focus on areas of
risk. What are these areas of modifiable risk? SATA - Smoking - Overweight - Lack
of exercise - Family history - Ethnicity - Smoking - Overweight - Lack of
exercise Explanation: Goals are not specific for peripheral vascular disease but
instead focus on areas of risks for such disease, such as smoking, overweight, and
lack of regular exercise. Family history and ethnicity are not modifiable risk
factors.
What pulse is located in the groove between the medial malleolus and the Achilles
tendon? a.Posterior tibial b.Dorsalis pedis c.Popliteal d.Femoral a.
Posterior tibial Explanation: The posterior tibial pulse is located in the groove
between the medial malleolus and the Achilles tendon. The femoral pulse is about
halfway between the symphysis pubis and the anterior iliac spine, just below the
inguinal ligament. The popliteal pulse is often difficult to locate. It may be felt
immediately lateral to the medial tendon. A light touch is important to avoid
obliterating the dorsalis pedis pulse. It is normally about halfway up the foot
immediately lateral to the extensor tendon of the great toe.
A nurse cares for a client who is postoperative cholecystectomy. Which action by
the nurse is appropriate to help prevent the occurrence of venous stasis? a.Raise
the foot of the bed for an hour and then lower it. b.Massage lower extremities
vigorously every 6 hours. c.Assist in active range-of-motion exercise of the upper
body. d.Assist the client to walk as soon and as often as possible. d.
Assist the client to walk as soon and as often as possible. Explanation:
Immobility creates an environment in which clotting (embolism formation) can be
caused by venous stasis. Active exercise such as having the client ambulate as soon
as possible will stimulate circulation and venous return. This reduces the
possibility of clot formation. Raising the foot of the bed, vigorous massage, and
active range of motion of the upper body may not prevent venous stasis.
A nurse receives an order to perform a compression test to assess the competence of
the valves in a client's varicose veins. Which action by the nurse demonstrates the
correct way to perform this test? a.Ask the client to sit on a chair for the
examination b.Firmly compress the lower portion of the varicose vein c.Place the
second hand 3 to 4 inches above the first hand d.Feel for a pulsation to the
fingers in the lower hand b. Firmly compress the lower portion of the
varicose vein Explanation: The nurse should firmly compress the lower portion of
the varicose vein with one hand. The nurse should ask the client to stand, not sit,
on a chair for the examination. The second hand should be placed 6 to 8 inches, not
3 to 4 inches, above the first hand. The nurse should feel for a pulsation to the
fingers in the upper hand.
While performing a routine check-up on an 81-year-old retired grain farmer in the
vascular surgery clinic, the nurse notes that he has a history of chronic arterial
insufficiency. Which of the following physical examination findings of the lower
extremities would be expected with this disease? a.Normal pulsation b.Normal
temperature c.Marked edema d.Thin, shiny, atrophic skin d. Thin, shiny,
atrophic skin Explanation: Thin, shiny, atrophic skin is more commonly seen in
chronic arterial insufficiency; in chronic venous insufficiency the skin often has
a brown pigmentation and may be thickened.
While assessing the peripheral vascular system of an adult client, the nurse
detects cold clammy skin and loss of hair on the client's legs. The nurse suspects
that the client may be experiencing? a.venous stasis. b.varicose veins.
c.thrombophlebitis. d.arterial insufficiency. d. arterial insufficiency.
Explanation: Manifestations of arterial insufficiency include intermittent
claudication to sharp, unrelenting, and constant. Diminished or absent pulses. Skin
in cool to cold in temperature and there is a loss of hair over the toes and dorsum
of the foot.
A 57-year-old maintenance worker comes to the office for evaluation of pain in his
legs. He is a two-pack per day smoker since the age of 16, but he is otherwise
healthy. The nurse is concerned that the client may have peripheral arterial
disease. Which of the following is a common symptom that could indicate peripheral
arterial disease? a.Intermittent claudication b.Chest pressure with exertion
c.Shortness of breath d.Knee pain a. Intermittent claudication
Explanation: Intermittent claudication is leg pain that occurs with walking and is
relieved by rest. It is a key symptom of peripheral arterial disease. This symptom
is present in only about one third of clients with significant arterial disease
and, if found, calls for more aggressive management of cardiovascular risk factors.
Screening with ankle-brachial index can help detect this problem.
A trauma client reports pain in the left lower extremity. The nurse notes that the
extremity has pallor. Pedal pulses are diminished, and paresthesia is present. What
nursing diagnosis might the nurse use? a.Pain related to decreased blood flow and
altered tissue perfusion b.Activity intolerance related to pain and claudication
with ambulation c.Altered tissue perfusion, arterial related to reduced blood flow
d.Risk for peripheral neurovascular dysfunction d. Risk for peripheral
neurovascular dysfunction Explanation: Those with risk for peripheral
neurovascular dysfunction are at risk for a disruption in circulation, sensation,
or motion of an extremity. Risk factors include trauma, fractures, mechanical
compression, surgery, burns, immobilization, and obstruction. The other options are
distracters to the question.
Which reading of the ankle-brachial pressure index (ABPI) should the nurse
recognize as indicative of a normal healthy person? a.0.15 b.0.25 c.0.75 d.1.00
d. 1.00 Explanation: The ankle pressure in a healthy person is the same or
slightly higher than the brachial pressure, resulting in an ABPI of approximately
1.00 or no arterial insufficiency. An ABPI of 0.25 or lower indicates severe
stenosis leading to ischemia and tissue damage. An ABPI of 0.5 to 0.95 indicates
mild to moderate arterial insufficiency.
When you enter the room of a hospitalized client, you note that the client is
guarding her left leg, which is swollen and reddened. You should identify the signs
and symptoms of what complication of hospitalization? a.Decreased mobility
b.Sepsis c.Venous thromboembolism d.Fluid imbalance c. Venous
thromboembolism Explanation: Edema, pain or achiness, erythema, and warmth in the
leg are common signs and symptoms of venous thromboembolism.
During an assessment, the nurse first performs the action shown (raising legs up).
After that the nurse asks the client to sit up with their legs dangling from the
edge of the table. What is the nurse assessing? a.Lymphedema b.Femoral pulse
c.Arterial insufficiency d.Intermittent claudication c. Arterial
insufficiency Explanation: The color change test is to check for arterial
insufficiency. With the client supine, the legs are elevated about 30 cm (12 in.)
above the level of the heart. Then when have the client sit up and dangle the legs.
Color should return to the feet and toes within 10 seconds. The superficial veins
of the feet fill within 15 seconds. Return of color taking longer than 10 seconds
or persistent dependent rubor indicates arterial insufficiency. This is not a
technique to assess lymphedema, the femoral pulse, or intermittent claudication.

The client is experiencing septic shock. What assessment finding would the nurse
expect to find? a.Blood pressure 128/76 b.Capillary refill greater than 2 seconds
c.Warm extremities d.Normal temperature b. Capillary refill greater than 2
seconds Explanation: The client experiencing septic shock would have a capillary
refill greater than 2 seconds. The temperature may or many not be normal, blood
pressure would be low and extremities would be cool.
During a physical examination, the nurse detects warm skin and brown pigmentation
around an adult client's ankles. The nurse suspects that the client may be
experiencing? a.venous insufficiency. b.arterial occlusive disease. c.venous
ulcers. d.ankle edema. a. venous insufficiency. Explanation: Manifestations
of venous insufficiency include cramping pain, thickened tough skin, and areas of
hyperpigmentation around the medial and lateral malleolus.
After palpating the radial pulse of an adult client, the nurse suspects arterial
insufficiency. The nurse should next assess the client's? a.femoral pulse.
b.popliteal pulse. c.brachial pulse. d.tibial pulse. c. brachial pulse.
Explanation: You can also palpate the brachial pulses if you suspect arterial
insufficiency. Do this by placing the first three fingertips of each hand at the
client's right and left medial antecubital creases.
In assessing a client, a nurse palpates her epitrochlear lymph nodes and notes that
the client may have an infection in the hand or forearm. The nurse understands that
which of the following are functions of the lymphatic system? SATA - Delivers
oxygen, water, and nutrients to the tissues - Returns blood to the heart - Drains
excess fluid and plasma proteins from tissues and returns them to the venous system
- Traps and destroys microorganisms and foreign materials filtered from lymph -
Absorbs fats from the small intestine into the bloodstream - Drains excess
fluid and plasma proteins from tissues and returns them to the venous system -
Traps and destroys microorganisms and foreign materials filtered from lymph -
Absorbs fats from the small intestine into the bloodstream Explanation: The
primary function of the lymphatic system is to drain excess fluid and plasma
proteins from bodily tissues and return them to the venous system. These
capillaries join to form larger vessels that pass through filters known as lymph
nodes. The filtering, trapping, and destruction of microorganisms, foreign
materials, dead blood cells, and abnormal cells by the lymph nodes allows the
lymphatic system to perform a second function as a major part of the immune system
defending the body against microorganisms. A third function of the lymphatic system
is to absorb fats (lipids) from the small intestine into the bloodstream. The
capillaries deliver oxygen, water, and nutrients to the tissues. Veins return blood
to the heart.
A nurse has just inspected a standing client's legs for varicosities. The nurse
would now like to assess for suspected phlebitis. Which of the following should the
nurse do next? a.Have the client sit down b.Use a Doppler ultrasound device on the
client's leg c.Lightly palpate the client's leg veins for tenderness d.Dorsiflex
the client's foot and apply light pressure lateral to and along the side of the
extensor tendon of the big toe c. Lightly palpate the client's leg veins
for tenderness Explanation: To fully assess for a suspected phlebitis, lightly
palpate for tenderness. The client should still be standing from the inspection of
the legs. A Doppler ultrasound device is used to assess for pulses when they are
difficult to palpate. Dorsiflexing the client's foot and applying light pressure
along the extensor tendon of the big toe are done when palpating for the dorsalis
pedis pulses.
The diagnosis of superficial phlebitis increases the client's risk for which
vascular disorder? a.deep vein thrombosis b.compartment syndrome c.acute
lymphangitis d.acute cellulitis a. deep vein thrombosis Explanation:
Superficial phlebitis is an inflammation of a superficial vein that can lead to
deep vein thrombosis. Compartment syndrome is a result of pressure building from
trauma or bleeding into one of the four major muscle compartments between the knee
and ankle. Acute lymphangitis is a bacterial infection from Streptococcus pyogenes
or Staphylococcus aureus, spreading up the lymphatic channels from a distal portal
of entry. Acute cellulitis is a bacterial infection of the skin and subcutaneous
tissues.
"A client diagnosed with intermittent claudication wonders why the nurse wants to
know where the client is experiencing cramping when walking. What would be the
nurse's best answer? a.""The area of pain tells us what treatment will work best
for you."" b.""The area of cramping indicates whether you may have numbness and
tingling also."" c.""The area of pain can help us identify what risk factor is
predominant."" d.""The area of cramping is close to the area of arterial
occlusion.""" "d. ""The area of cramping is close to the area of arterial
occlusion."" Explanation: The area of cramping in arterial disease, termed
intermittent claudication, closely approximates the level of arterial occlusion.
The other options are distracters to the question."
If palpable, superficial inguinal nodes are expected to be? a.Fixed, tender, and
at 2.5 cm in diameter b.Discrete, tender, and 2 cm in diameter c.Nontender, mobile,
and 1 cm in diameter d.Fixed, nontender, and 1.5 cm in diameter c.
Nontender, mobile, and 1 cm in diameter Explanation: Healthy lymph nodes are
nontender and mobile. Inguinal lymph nodes can be 1 to 2 cm in diameter.
On inspection of a client's legs, the nurse has found varicose veins. Which test
should the nurse next perform to determine the competence of the saphenous vein
valves? a.Trendelenburg test b.Ankle-brachial pressure index (ABPI) c.Position
change test d.Allen test a. Trendelenburg test Explanation: If the
client has varicose veins, perform the Trendelenburg test to determine the
competence of the saphenous vein valves and the retrograde (backward) filling of
the superficial veins. The ABPI is considered an accurate objective assessment for
determining the degree of peripheral arterial disease. The position change test is
done to further assess for arterial insufficiency in the legs following the
determination of weak pulses. The Allen test evaluates patency of the radial or
ulnar arteries. It is implemented when patency is questionable or before such
procedures as a radial artery puncture.
A nurse experiences difficulty with palpation of the dorsalis pedis pulse in a
client with arterial insufficiency. What is an appropriate action by the nurse
based on this finding? a.Attempt to palpate the posterior tibial pulse. b.Assess
adequacy of blood flow using a Doppler device. c.Check the extremity for findings
of decreased blood flow. d.Obtain an order for ankle brachial index test to be
performed. b. Assess adequacy of blood flow using a Doppler device.
Explanation: Arterial insufficiency causes a decrease in the amount of blood flow
to an extremity. If the blood flow is diminished significantly, the adequacy of the
pulse may also diminish. Therefore, if a pulse cannot be palpated, the nurse's
best action is to obtain a Doppler device to assess for adequate blood flow. A
Doppler device works by transmitting ultra-high-frequency sound waves in a way that
they strike red blood cells in an artery or vein. This rebounding ultrasound waves
produces a whooshing sound that is transmitted through the Doppler. Attempting to
palpate the posterior tibial pulse does not provide information about the dorsalis
pedis pulse. Checking the extremity for findings of decreased blood flow is not
necessary because the nurse is already aware that the client has arterial
insufficiency and needs to determine the extent, not the presence, of the disease.
The ankle brachial index is a much more complex test that can be performed after
the Doppler determines whether or not a pulse is present.
Which of the following wounds is most likely attributable to neuropathy? a.A
painful wound in the client's shin, which is surrounded by apparently healthy skin
b.A moderately painful wound on the lateral aspect of the client's ankle c.A
painless wound on the sole of the client's foot, which is surrounded by calloused
skin d.A wound on a client's highly edematous ankle that is surrounded by pigmented
ski c. A painless wound on the sole of the client's foot, which is
surrounded by calloused skin Explanation: Neuropathic ulcers tend to develop on
pressure points, such as the sole of the foot, and are often free of pain. Painful
wounds surrounded by healthy skin are associated with arterial
insufficiencyModerately painful ankle wounds surrounded by pigmented skin are often
associated with venous ulcers
A nurse performs the Trendelenburg test for a client with varicose veins. Which
action should the nurse take when performing this test? a.Legs should be elevated
for 15 seconds b.Tourniquet should be put on before leg elevation c.Have the client
stand upright after tourniquet removal d.Ensure that the client's legs are over the
side of the bed a. Legs should be elevated for 15 seconds Explanation:
When performing the Trendelenburg test, the nurse should elevate the client's leg
for 15 seconds to empty the veins. The tourniquet should be put on after leg
elevation. The client should stand upright with the tourniquet on the leg. The
client is not asked to sit with the leg hanging down when performing the
Trendelenburg test.
A nurse palpates a weak left radial artery on a client. What should the nurse do
next? a.Palpate both radial arteries for symmetry. b.Assess the left hand for
pallor and coolness. c.Palpate the left ulnar artery. d.Document the finding in the
client's record. a. Palpate both radial arteries for symmetry. Explanation:
Extremities should always be assessed simultaneously for symmetry. If the radial
arteries are both weak, this may indicate a problem with peripheral circulation.
The nurse should then assess the ulnar artery pulses to determine the presence of
arterial insufficiency. The hands should be assessed for pallor and coolness, which
would also be present with arterial insufficiency.
After assessing pitting edema below the knee in a client, the nurse would suspect
that which artery may be occluded? a.popliteal b.iliofemoral c.saphenous
d.communicating a. popliteal Explanation: Although normal popliteal
arteries may be nonpalpable, an absent pulse may also be the result of an occluded
artery. Further circulatory assessment such as temperature changes, skin-color
differences, edema, hair distribution variations, and dependent rubor (dusky
redness) distal to the popliteal artery assists in determining the significance of
an absent pulse.
A client has a brownish discoloration of the skin of both lower legs. What should
the nurse suspect is occurring with this client? a.atherosclerosis b.arterial
insufficiency c.venous insufficiency d.deep vein thrombosis c. venous
insufficiency Explanation: Brownish discoloration just above the malleolus
suggests chronic venous insufficiency. There are no specific skin changes
associated with atherosclerosis. The lower extremities in the dependent position
would be pale in color in arterial insufficiency. The extremity would be warm and
edematous with a deep vein thrombosis.
A nurse is working with a client who demonstrates venous stasis in his legs. The
nurse understands that there must be a problem with one of the mechanisms of venous
function that help to propel blood back to the heart. Which of the following are
included among these mechanisms? SATA - One-way valves in the veins - Skeletal
muscle contraction - Pumping action of the heart - Gravity - Pressure gradient
produced by inspiration - One-way valves in the veins - Skeletal muscle
contraction - Pressure gradient produced by inspiration Explanation: Three
mechanisms of venous function help to propel blood back to the heart. The first
mechanism has to do with the structure of the veins. Deep, superficial, and
perforator veins all contain one-way valves. These valves permit blood to pass
through them on the way to the heart and prevent blood from returning through them
in the opposite direction. The second mechanism is muscular contraction. Skeletal
muscles contract with movement and, in effect, squeeze blood toward the heart
through the one-way valves. The third mechanism is the creation of a pressure
gradient through the act of breathing. Inspiration decreases intrathoracic pressure
while increasing abdominal pressure, thus producing a pressure gradient.
A client complains of pain in the calves, thighs, and buttocks whenever he climbs
more than a flight of stairs. This pain, however, is quickly relieved as soon as he
sits down and rests. The nurse should suspect which of the following conditions in
this client? a.Advanced chronic arterial occlusive disease b.Neuropathy secondary
to diabetes c.Venous disease d.Peripheral arterial disease d. Peripheral
arterial disease Explanation: Intermittent claudication is characterized by
weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs,
or buttocks but rarely in the feet with activity. These symptoms are quickly
relieved by rest but reproducible with same degree of exercise and may indicate
peripheral arterial disease (PAD). Leg pain that awakens a client from sleep is
often associated with advanced chronic arterial occlusive disease. A lack of pain
sensation may signal neuropathy in such disorders as diabetes. Heaviness and an
aching sensation aggravated by standing or sitting for long periods of time and
relieved by rest are associated with venous disease.
Which of the following veins drain into the superior vena cava? SATA - Lower
extremities - Upper torso - Head - Upper extremities - Lower torso -
Upper torso - Head - Upper extremities Explanation: The veins of the upper
extremities, upper torso, head, and neck drain into the superior vena cava and then
the right atrium. The lower extremities and lower torso drain into the inferior
vena cava.
A 77-year-old retired nurse has an ulcer on a lower extremity. All the following
diseases are responsible for causing ulcers in the lower extremities except for?
a.Arterial insufficiency b.Venous insufficiency c.Diminished sensation in pressure
points d.Hypertension d. Hypertension Explanation: Hypertension is not
directly associated with the formation of ulcers. It is an indirect risk factor if
it is uncontrolled for a long time and associated with atherosclerosis, because it
can lead to arterial insufficiency or neuropathy.
A client has been diagnosed with venous insufficiency. Which of the following
findings should the nurse expect on interviewing this client? a.Cold, pale skin on
the extremities b.Shiny skin, with loss of hair over the lower legs c.Warm skin and
brown pigmentation around the ankles d.Clammy skin on the extremities c.
Warm skin and brown pigmentation around the ankles Explanation: Warm skin and
brown pigmentation around the ankles are associated with venous insufficiency.
Cold, pale, clammy skin on the extremities and thin, shiny skin with loss of hair,
especially over the lower legs, are associated with arterial insufficiency.
The nurse is assessing an older adult. The client states that she feels a constant,
sharp pain only when walking. The nurse suspects the client is experiencing what?
a.Intermittent claudication b.Pulmonary embolism c.Deep vein thrombosis d.Varicose
veins a. Intermittent claudication Explanation: Pain brought on by exertion
and relieved by rest is called intermittent claudication. Varicose veins are due
to incompetent valves. Signs of a pulmonary embolus include acute dyspnea, chest
pain, tachycardia, diaphoresis,anxiety. Deep vein thrombosis symptoms include pain,
edema, and warmth of an extremity.
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 developing an
individualized care plan for her, the nurse determines that the most important risk
factors for peripheral artery disease (PAD) that needs to be modified? a. weight
and diet. b. activity level and diet. c. tobacco use and high blood pressure. d.
sedentary lifestyle and high blood pressure. c. tobacco use and high blood
pressure. Significant risk factors for peripheral artery disease include tobacco
use, hyperlipidemia, elevated levels of high-sensitivity C-reactive protein,
diabetes mellitus, and uncontrolled hypertension; the most important is tobacco
use. Other risk factors include family history, hypertriglyceridemia,
hyperuricemia, increasing age, obesity, sedentary lifestyle, and stress.
Rest pain is a manifestation of PAD that occurs due to a chronic a. vasospasm of
small cutaneous arteries in the feet. b. increase in retrograde venous blood flow
in the 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. c.
decrease in arterial blood flow to the nerves of the feet. Rest pain most often
occurs in the forefoot or toes and is aggravated by limb elevation. Rest pain
occurs when blood flow is insufficient to meet basic metabolic requirements of the
distal tissues. Rest pain occurs more often at night because cardiac output tends
to drop during sleep and the limbs are at the level of the heart. Patients often
try to achieve partial pain relief by dangling the leg over the side of the bed or
sleeping in a chair to allow gravity to maximize blood flow.
A patient with infective endocarditis develops sudden left leg pain with pallor,
paresthesia, and a loss of peripheral pulses. The nurse's initial action should be
to? a. elevate the leg to promote venous return. b. start anticoagulant therapy
with IV heparin. c. notify the physician of the change in peripheral perfusion. d.
place the bed in reverse Trendelenburg to promote perfusion. c. notify
the physician of the change in peripheral perfusion. The patient has potentially
developed acute arterial ischemia (sudden interruption in the arterial blood supply
to the extremity), caused by an embolism from a cardiac thrombus that occurred as a
complication of infective endocarditis. Clinical manifestations of acute arterial
ischemia include any or all of the six Ps : pain, pallor, paralysis, pulselessness,
paresthesia, and poikilothermia. Without immediate intervention, ischemia may
progress quickly to tissue necrosis and gangrene within a few hours. If the nurse
detects these signs, the physician should be notified immediately.
Which clinical manifestations are seen in patients with either Buerger's disease or
Raynaud's phenomenon? SATA a. Intermittent fevers b. Sensitivity to cold
temperatures c. Gangrenous ulcers on fingertips d. Color changes of fingers and
toes e. Episodes of superficial vein thrombosis b. Sensitivity to cold
temperatures c. Gangrenous ulcers on fingertips d. Color changes of fingers and
toes Both Buerger's disease and Raynaud's phenomenon have the following clinical
manifestations in common: cold sensitivity, ischemic and gangrenous ulcers on
fingertips, and color changes of the distal extremity (fingers or toes).
A patient 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
b. Sudden, severe low back pain and bruising along his flank The clinical
manifestations of a ruptured abdominal aortic aneurysm include severe back pain,
back or flank ecchymosis - Grey Turner's sign, and hypovolemic shock (tachycardia,
hypotension, tachypnea, pale clammy skin, decreased urine output, altered level of
consciousness, and abdominal tenderness).
Priority nursing measures after an abdominal aortic aneurysm repair include 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 elastic compression stockings
c. administration of IV fluids and monitoring of kidney function.
Postoperative priorities include administration of IV fluids and maintenance of
renal perfusion. An adequate blood pressure is important for maintaining graft
patency, and administration of IV fluids and blood components (as indicated) is
essential for adequate blood flow. The nurse should evaluate renal function by
measuring hourly urine output and monitoring daily blood urea nitrogen (BUN) and
serum creatinine levels. Irreversible renal failure may occur after aortic surgery,
particularly in individuals at high risk.
The first priority of collaborative care of a patient with a suspected acute aortic
dissection is to? a. reduce anxiety. b. control blood pressure. c. monitor for
chest pain. d. increase myocardial contractility. b. control blood
pressure. The initial goals of therapy for acute aortic dissection without
complications are blood pressure (BP) control and pain management. BP control
reduces stress on the aortic wall by reducing systolic BP and myocardial
contractility.
The patient at highest risk for venous thromboembolism 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 labor. d. an active 72-year-old man at home recovering from
transurethral resection of the prostate for benign prostatic hyperplasia.
b. a 32-year-old woman who smokes, takes oral contraceptives, and is planning
a trip to Europe. Three important factors (called Virchow's triad) in the etiology
of venous thrombosis are venous stasis, damage of the endothelium (inner lining of
the vein), andhypercoagulability of the blood. Patients at risk for venous
thrombosis usually have predisposing conditions for these three disorders. The 32-
year-old woman has the highest risk: long trips without adequate exercise (venous
stasis), tobacco use, and use of oral contraceptives. The likelihood of
hypercoagulability of blood is increased in women older than 35 years who use
tobacco.
Which are probable clinical findings in a person with an acute lower extremity
venous thromboembolism? SATA 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 b. Mild to moderate calf pain and tenderness d. Unilateral
edema and induration of the thigh The patient with lower extremity venous
thromboembolism (VTE) may or may not have unilateral leg edema, extremity pain, a
sense of fullness in the thigh or calf, paresthesias, warm skin, erythema, or a
systemic temperature greater than 100.4 F (38 C). If the calf is involved, it may
be tender to palpation.
The recommended treatment for an initial venous thromboembolism in an otherwise
healthy person with no significant co-morbidities would include a. IV argatroban
(Acova) as an inpatient. b. IV unfractionated heparin as an inpatient. c.
subcutaneous unfractionated heparin as an outpatient. d. subcutaneous low-
molecular-weight heparin as an outpatient. d. subcutaneous low-
molecular-weight heparin as an outpatient. Patients with confirmed VTE should
receive initial treatment with low-molecular-weight heparin (LMWH), unfractionated
heparin (UH), fondaparinux, or rivaroxaban, followed by warfarin for 3 months to
maintain the international normalized ratio (INR) between 2.0 and 3.0 for 24 hours.
Patients with multiple comorbid conditions, complex medical issues, or a very large
VTE usually are hospitalized for treatment and typically receive intravenous UH.
LMWH only for 3 months is another option for patients with acute VTE. Depending on
the clinical presentation, patients often can be managed safely and effectively as
outpatients.
A key aspect of teaching for the patient on anticoagulant therapy includes which
instructions? 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 drug
levels. a. Monitor for and report any signs of bleeding. Patients taking
anticoagulants should be taught to monitor and report any signs of bleeding, which
can be a serious complication. Other important patient teaching includes
maintenance of a consistent intake of foods containing vitamin K, avoidance of
supplements that contain vitamin K, and routine coagulation laboratory studies if a
patient is taking warfarin.
In planning care and patient teaching for the patient with venous leg ulcers, the
nurse recognizes that the most important intervention in healing and control of
this condition is a. sclerotherapy. b. using moist environment dressings. c. taking
horse chestnut seed extract daily. d. applying elastic compression stockings.
d. applying elastic compression stockings. Compression is essential for
treating chronic venous insufficiency (CVI), healing venous ulcers, and preventing
ulcer recurrence. Use of custom-fitted elastic compression stockings is one option
for compression therapy.
A nurse is caring for a patient with a diagnosis of deep venous thrombosis (DVT).
The patient has an order to receive 30 mg enoxaparin (Lovenox). Which injection
site should the nurse use to administer this medication safely? a. Buttock, upper
outer quadrant b. Abdomen, anterior-lateral aspect c. Back of the arm, 2 inches
away from a mole d. Anterolateral thigh, with no scar tissue nearby b.
Abdomen, anterior-lateral aspect Enoxaparin (Lovenox) is a low-molecular-weight
heparin that is given as a deep subcutaneous injection in the right and left
anterolateral abdomen. All subcutaneous injections should be given away from scars,
lesions, or moles.
The nurse is preparing to administer a scheduled dose of enoxaparin (Lovenox) 30 mg
subcutaneously. What should the nurse do to administer this medication correctly?
a. Remove the air bubble in the prefilled syringe. b. Aspirate before injection to
prevent IV administration. c. Rub the injection site after administration to
enhance absorption. d. Pinch the skin between the thumb and forefinger before
inserting the needle "d. Pinch the skin between the thumb and forefinger
before inserting the needle The nurse should gather together or ""bunch up"" the
skin between the thumb and the forefinger before inserting the needle into the
subcutaneous tissue. The nurse should not remove the air bubble in the prefilled
syringe, aspirate, nor rub the site after injection."
The nurse is admitting a 68-year-old preoperative patient with a suspected
abdominal aortic aneurysm (AAA). The medication history reveals that the patient
has been taking warfarin (Coumadin) on a daily basis. Based on this history and the
patient's admission diagnosis, the nurse should prepare to administer which
medication? a. Vitamin K b. Cobalamin c. Heparin sodium d. Protamine sulfate
a. Vitamin K Coumadin is a Vitamin K antagonist 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
(Coumadin).
The nurse is caring for a patient who has been receiving warfarin (Coumadin) and
digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has
been discontinued before surgery, the nurse should diligently assess the patient
for which complication early in the postoperative period until the medication is
resumed? a. Decreased cardiac output b. Increased blood pressure c. Cerebral or
pulmonary emboli d. Excessive bleeding from incision or IV sites c.
Cerebral or pulmonary emboli 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 thrombi detach
from the atrial wall, they could travel as cerebral emboli from the left atrium or
pulmonary emboli from the right atrium.
The nurse is reviewing the laboratory test results for a 68-year-old patient whose
warfarin (Coumadin) therapy was terminated during the preoperative period. The
nurse concludes that the patient is in the most stable condition for surgery after
noting which INR (international normalized ratio) result? a. 1.0 b. 1.8 c. 2.7 d.
3.4 a. 1.0 The therapeutic range for INR is 2.0 to 3.0 for many clinical
diagnoses. The larger the INR 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.
The nurse would determine that a postoperative patient is not receiving the
beneficial effects of enoxaparin (Lovenox) after noting what during a routine shift
assessment? a. Generalized weakness and fatigue b. Crackles bilaterally in the
lung bases c. Pain and swelling in lower extremity d. Abdominal pain with
decreased bowel sounds c. Pain and swelling in lower extremity Enoxaparin is
a low-molecular-weight heparin 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 DVT and therefore may signal ineffective
medication therapy.
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 result?
a. 1.0 b. 1.2 c. 1.6 d. 2.2 d. 2.2 Vitamin K is the antidote to warfarin
(Coumadin), which the patient has most likely been taking before 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.
"A postoperative patient asks the nurse why the physician ordered daily
administration of enoxaparin (Lovenox). Which reply by the nurse is most
appropriate? 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.""" "c. ""This medication will
help prevent blood clots from forming in your legs until your level of activity,
such as walking, returns to normal."" Enoxaparin is an anticoagulant that is used
to prevent DVTs postoperatively. All other explanations/options do not describe the
action/purpose of enoxaparin."
The nurse is caring for a preoperative patient who has an order for vitamin K by
subcutaneous injection. The nurse should verify that which laboratory study is
abnormal before administering the dose? a. Hematocrit (Hct) b. Hemoglobin (Hgb) c.
Prothrombin time (PT) d. Partial thromboplastin time (PTT) c. Prothrombin
time (PT) Vitamin K counteracts hypoprothrombinemia and/or reverses the effects of
warfarin (Coumadin) and thus decreases the risk of bleeding. High values for
either the prothrombin time (PT) or the international normalized ratio (INR)
demonstrates the need for this medication.
The nurse is caring for a newly admitted patient with vascular insufficiency. The
patient has a new order for enoxaparin (Lovenox) 30 mg subcutaneously. What 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. b. Leave the air bubble in the prefilled syringe. 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.
What is a priority nursing intervention in the care of a patient with a diagnosis
of chronic venous insufficiency (CVI)? a. Application of topical antibiotics to
venous ulcers b. Maintaining the patient's legs in a dependent position c.
Administration of oral and/or subcutaneous anticoagulants d. Teaching the patient
the correct use of compression stockings d. Teaching the patient the correct
use of compression stockings 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.
"A patient with varicose veins has been prescribed compression stockings. How
should the nurse teach the patient to use these? a. ""Try to keep your stockings
on 24 hours a day, as much as possible."" 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."""
"b. ""While you're still lying in bed in the morning, put on your
stockings."" 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."
Assessment of a patient's peripheral IV site reveals that phlebitis has developed
over the past several hours. Which intervention should the nurse implement first?
a. Remove the patient's IV catheter. Correct b. Apply an ice pack to the affected
area. c. Decrease the IV rate to 20 to 30 mL/hr. d. Administer prophylactic
anticoagulants. a. Remove the patient's IV catheter. Correct 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.
A 62-year-old Hispanic male patient with diabetes mellitus has been diagnosed with
peripheral artery disease (PAD). The patient is a smoker and has a history of gout.
What should the nurse focus her teaching on to prevent complications for this
patient? a. Gender b. Smoking c. Ethnicity d. Co-morbidities b. Smoking
Smoking is the most significant factor for this patient. PAD is a marker of
advanced systemic atherosclerosis. Therefore tobacco cessation is essential to
reduce PAD progression, CVD events, and mortality. Diabetes mellitus and
hyperuricemia are also risk factors. Being male or Hispanic are not risk factors
for PAD.
What medications should the nurse expect to include in the teaching plan to
decrease the risk of cardiovascular events and death for PAD patients? SATA a.
Ramipril (Altace) b. Cilostazol (Pletal) c. Simvastatin (Zocor) d. Clopidogrel
(Plavix) e. Warfarin (Coumadin) f. Aspirin (acetylsalicylic acid) a.
Ramipril (Altace) c. Simvastatin (Zocor) d. Clopidogrel (Plavix) Angiotensin-
converting enzyme inhibitors (e.g., ramipril [Altace]) are used to control
hypertension. Statins (e.g., simvastatin [Zocor]) are used for lipid management.
Aspirin is used as an antiplatelet agent. Cilostazol (Pletal) is used for
intermittent claudication, but it does not reduce CVD morbidity and mortality
risks. Clopidogrel may be used if the patient cannot tolerate aspirin.
Anticoagulants (e.g., warfarin [Coumadin]) are not recommended to prevent CVD
events in PAD patients.
A female patient with critical limb ischemia has had peripheral artery bypass
surgery to improve her circulation. What care should the nurse provide on
postoperative day 1? a. Keep the patient on bed rest. b. Assist the patient with
walking several times. c. Have the patient sit in the chair several times. d.
Place the patient on her side with knees flexed. b. Assist the patient
with walking several times. To avoid blockage of the graft or stent, the patient
should walk several times on postoperative day 1 and subsequent days. Having the
patient's knees flexed for sitting in a chair or in bed increase the risk of venous
thrombosis and may place stress on the suture lines.
A patient was just diagnosed with acute arterial ischemia in the left leg secondary
to atrial fibrillation. Which early clinical manifestation must be reported to the
physician immediately to save the patient's limb? a. Paralysis b. Paresthesia c.
Crampiness d. Referred pain b. Paresthesia The physician must be notified
immediately if any of the six Ps of acute arterial ischemia occur to prevent
ischemia from quickly progressing to tissue necrosis and gangrene. The six Ps are
paresthesia, pain, pallor, pulselessness, and poikilothermia, with paralysis being
a very late sign indicating the death of nerves to the extremity. Crampy leg
sensation is more common with varicose veins.
A 40-year-old man tells the nurse he has a diagnosis for the color and temperature
changes of his limbs but can't remember the name of it. He says he must stop
smoking and avoid trauma and avoid exposure of his limbs to cold temperatures to
get better. This description should allow the nurse to ask the patient if he has
which diagnosis? a. Buerger's disease b. Venous thrombosis c. Acute arterial
ischemia d. Raynaud's phenomenon a. Buerger's disease Buerger's disease is
a nonatherosclerotic, segmental, recurrent inflammatory disorder of small and
medium-sized veins and arteries of upper and lower extremities leading to color and
temperature changes of the limbs, intermittent claudication, rest pain, and
ischemic ulcerations.It primarily occurs in men younger than 45 years old with a
long history of tobacco and/or marijuana use.Buerger's disease treatment includes
smoking cessation, trauma and cold temperature avoidance, and a walking
programVenous thrombosis is the formation of a thrombus in association with
inflammation of the vein. Acute arterial ischemia is a sudden interruption in
arterial blood flow to a tissue caused by embolism, thrombosis, or trauma.
Raynaud's phenomenon is characterized by vasospasm-induced color changes of the
fingers, toes, ears, and nose.
A male patient was admitted for a possible ruptured aortic aneurysm, but had no
back pain. Ten minutes later his assessment includes the following: sinus
tachycardia at 138, BP palpable at 65 mm Hg, increasing waist circumference, and no
urine output. How should the nurse interpret this assessment about the patient's
aneurysm? a. Tamponade will soon occur. b. The renal arteries are involved. c.
Perfusion to the legs is impaired. d. He is bleeding into the abdomen. d. He
is bleeding into the abdomen. The lack of back pain indicates the patient is most
likely exsanguinating into the abdominal space, and the bleeding is likely to
continue without surgical repair. A blockade of the blood flow will not occur in
the abdominal space as it would in the retroperitoneal space where surrounding
anatomic structures may control the bleeding. The lack of urine output does not
indicate renal artery involvement, but that the bleeding is occurring above the
renal arteries, which decreases the blood flow to the kidneys. There is no
assessment data indicating decreased perfusion to the legs.
The patient had aortic aneurysm repair. What priority nursing action will the nurse
use to maintain graft patency? a. Assess output for renal dysfunction. b. Use IV
fluids to maintain adequate BP. c. Use oral antihypertensives to maintain cardiac
output. d. Maintain a low BP to prevent pressure on surgical site b. Use
IV fluids to maintain adequate BP. The priority is to maintain an adequate BP
(determined by the surgeon) to maintain graft patency. A prolonged low BP may
result in graft thrombosis, and hypertension may cause undue stress on arterial
anastomoses resulting in leakage of blood or rupture at the suture lines, which is
when IV antihypertensives may be used.
When the patient is being examined for venous thromboembolism (VTE) in the calf,
what diagnostic test should the nurse expect to teach the patient about first? a.
Duplex ultrasound b. Contrast venography c. Magnetic resonance venography d.
Computed tomography venography a. Duplex ultrasound The duplex
ultrasound is the most widely used test to diagnose VTE. Contrast venography is
rarely used now. Magnetic resonance venography is less accurate for calf veins than
pelvic and proximal veins. Computed tomography venography may be used but is
invasive and much more expensive than the duplex ultrasound.
The patient reports tenderness when she touches her leg over a vein. The nurse
assesses warmth and a palpable cord in the area. The nurse knows the patient needs
treatment to prevent which sequelae? a. Pulmonary embolism b. Pulmonary
hypertension c. Post-thrombotic syndrome d. Venous thromboembolism d.
Venous thromboembolism The clinical manifestations are characteristic of a
superficial vein thrombosis. If untreated, the clot may extend to deeper veins, and
venous thromboembolism may occur.
The patient has CVI and a venous ulcer. The unlicensed assistive personnel (UAP)
decides to apply compression stockings because that is what these patients always
have ordered. What assessment by the nurse would cause the application of
compression stockings to harm the patient? a. Rest pain b. High blood pressure c.
Elevated blood sugar d. Dry, itchy, flaky skin a. Rest pain Rest pain occurs
as peripheral artery disease (PAD) progresses and involves multiple arterial
segments. Compression stockings should not be used on patients with PAD. Elevated
blood glucose, possibly indicating uncontrolled diabetes mellitus, and hypertension
may or may not indicate arterial problems. Dry, itchy, flaky skin indicates venous
insufficiencyThe RN should be the one to obtain the order and instruct the UAP to
apply compression stockings if they are ordered.
Which person should the nurse identify as having the highest risk for abdominal
aortic aneurysm? a. A 70-year-old male, with high cholesterol and hypertension b.
A 40-year-old female with obesity and metabolic syndrome c. A 60-year-old male with
renal insufficiency who is physically inactive d. A 65-year-old female with
hyperhomocysteinemia and substance abuse a. A 70-year-old male, with high
cholesterol and hypertension The most common etiology of descending abdominal
aortic aneurysm (AAA) is atherosclerosis. Male gender, age 65 years or older, and
tobacco use are the major risk factors for AAAs of atherosclerotic origin. Other
risk factors include the presence of coronary or peripheral artery disease, high
blood pressure, and high cholesterol.
A 67-year-old man with peripheral artery disease is seen in the primary care
clinic. Which symptom reported by the patient would indicate to the nurse that the
patient is experiencing intermittent claudication? a. Patient complains of chest
pain with strenuous activity. b. Patient says muscle leg pain occurs with continued
exercise. c. Patient has numbness and tingling of all his toes and both feet. d.
Patient states the feet become red if he puts them in a dependent position.
b. Patient says muscle leg pain occurs with continued exercise. Intermittent
claudication is an ischemic muscle ache or pain that is precipitated by a
consistent level of exercise, resolves within 10 minutes or less with rest, and is
reproducible. Angina is the term used to describe chest pain with exertion.
Paresthesia is the term used to describe numbness or tingling in the toes or feet.
Reactive hyperemia is the term used to describe redness of the foot; if the limb is
in a dependent position the term is dependent rubor.
A 32-year-old female is prescribed diltiazem (Cardizem) for Raynaud's phenomenon.
To evaluate the patient's expected response to this medication, what is most
important for the nurse to assess? a. Improved skin turgor b. Decreased cardiac
rate c. Improved finger perfusion d. Decreased mean arterial pressure c.
Improved finger perfusion Raynaud's phenomenon is an episodic vasospastic disorder
of small cutaneous arteries, most frequently involving the fingers and toes.
Diltiazem (Cardizem) is a calcium channel blocker that relaxes smooth muscles of
the arterioles by blocking the influx of calcium into the cells, thus reducing the
frequency and severity of vasospastic attacks. Perfusion to the fingertips is
improved and vasospastic attacks reduced. Diltiazem may decrease heart rate and
blood pressure, but that is not the purpose in Raynaud's phenomenon. Skin turgor is
most often a reflection of hydration status.
A 39-year-old woman with a history of smoking and oral contraceptive use is
admitted with a venous thromboembolism (VTE) and prescribed unfractionated heparin.
What laboratory test should the nurse review to evaluate the expected effect of the
heparin? a. Platelet count b. Activated clotting time (ACT) c. International
normalized ratio (INR) d. Activated partial thromboplastin time (APTT) d.
Activated partial thromboplastin time (APTT) Unfractionated heparin can be given by
continuous IV for VTE treatment. When given IV, heparin requires frequent
laboratory monitoring of clotting status as measured by activated partial
thromboplastin time (aPTT).
A 73-year-old man with dementia has a venous ulcer related to chronic venous
insufficiency. The nurse should provide education on which type of diet for this
patient and his caregiver? a. Low-fat diet b. High-protein diet c. Calorie-
restricted diet d. High-carbohydrate diet b. High-protein diet A patient with
a venous ulcer should have a balanced diet with adequate protein, calories, and
micronutrients; this type of diet is essential for healing. Nutrients most
important for healing include protein, vitamins A and C, and zinc. Foods high in
protein (e.g., meat, beans, cheese, tofu), vitamin A (green leafy vegetables),
vitamin C (citrus fruits, tomatoes, cantaloupe), and zinc (meat, seafood) must be
provided. Restricting fat or calories is not helpful for wound healing or in
patients of normal weight. For overweight individuals with no active venous ulcer,
a weight-loss diet should be considered.
The nurse is taking a health history of a new client who reports pain in the left
lower leg and foot when walking. This pain is relieved with rest, and the nurse
observes that the left lower leg is slightly edematous and is hairless. When
planning this client's care, the nurse should most likely address which health
problem? A. Coronary artery disease (CAD) B. Intermittent claudication C.
Arterial embolus D. Raynaud disease B. Intermittent claudication A muscular,
cramp-type pain in the extremities consistently reproduced with the same degree of
exercise or activity and relieved by rest is experienced by clients with peripheral
arterial insufficiency. Referred to as intermittent claudication, this pain is
caused by the inability of the arterial system to provide adequate blood flow to
the tissues in the face of increased demands for nutrients and oxygen during
exercise.
While assessing a client, the nurse notes that the client's ankle-brachial index
(ABI) of the right leg is 0.40. How should the nurse best follow up this assessment
finding? A. Assess the client's use of over-the-counter dietary supplements. B.
Implement interventions relevant to arterial narrowing. C. Encourage the client to
increase intake of foods high in vitamin K. D. Adjust the client's activity level
to accommodate decreased coronary output. B. Implement interventions relevant
to arterial narrowing. ABI is used to assess the degree of stenosis of peripheral
arteries. An ABI of less than 1.0 indicates possible claudication of the
peripheral arteries. It does not indicate inadequate coronary output.
The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse
learns during the admission assessment that the client takes oral contraceptives.
The nurse's postoperative plan of care should include what intervention? A. Early
ambulation and leg exercises B. Cessation of the oral contraceptives until 3 weeks'
postoperative C. Doppler ultrasound of peripheral circulation twice daily D.
Dependent positioning of the client's extremities when at rest A. Early
ambulation and leg exercises Oral contraceptive use increases blood coagulability
with bed rest, the client may be at increased risk of developing deep vein
thrombosis. Leg exercises and early ambulation are among the interventions that
address this risk.
A nurse is creating an education plan for a client with venous insufficiency. Which
measure should the nurse include in the plan? A. Avoid normal stockings that are
tight. B. Limit activities, including walking. C. Sleep with legs below heart
level. D. Refrain from using graduated compression stockings. A. Avoid
normal stockings that are tight. Measures taken to prevent complications include
avoiding tight-fitting socks and panty girdles; maintaining activities, such as
walking; sleeping with legs elevated; and using pressure stockings. Not included
in the teaching plan for venous insufficiency would be reducing activity, sleeping
with legs dependent, and avoiding pressure stockings. Each of these actions
exacerbates venous insufficiency.
An occupational health nurse is providing an educational event and has been asked
by an administrative worker about the risk of varicose veins. Which action should
the nurse suggest as a preventive measure for varicose veins? A. Sit with crossed
legs for a few minutes each hour to promote relaxation. B. Walk for several
minutes every hour to promote circulation. C. Elevate the legs when tired. D. Wear
snug-fitting ankle socks to decrease edema. B. Walk for several minutes
every hour to promote circulation. A proactive approach to preventing varicose
veins would be to walk for several minutes every hour to promote circulation.
Sitting with crossed legs may promote relaxation, but it is contraindicated for
clients with, or at risk for, varicose veins. Elevating the legs only helps blood
passively return to the heart and does not help maintain the competency of the
valves in the veins. Wearing tight ankle socks is contraindicated for clients with,
or at risk for, varicose veins; socks that are below the muscles of the calf do not
promote venous return the socks simply capture the blood and promote venous stasis.

"The triage nurse in the emergency department is assessing a client who reports
pain and swelling in the right lower leg. The client's pain became much worse last
night and appeared along with fever, chills, and sweating. The client states, ""I
hit my leg on the car door 4 or 5 days ago, and it has been sore ever since."" The
client has a history of chronic venous insufficiency. Which intervention should the
nurse anticipate for this client? A. Platelet transfusion to treat
thrombocytopenia B. Warfarin to treat arterial insufficiency C. Antibiotics to
treat cellulitis D. Intravenous heparin to treat venous thromboembolism (VTE)"
C. Antibiotics to treat cellulitis Cellulitis is the most common infectious
cause of limb swelling. The signs and symptoms include acute onset of swelling,
localized redness, and pain; it is frequently associated with systemic signs of
fever, chills, and sweating.
A nurse in a long-term care facility is caring for an 83-year-old client who has a
history of heart failure (HF) and peripheral arterial disease (PAD). At present,
the client is unable to stand or ambulate. The nurse should implement measures to
prevent which complication? A. Aortitis B. Deep vein thrombosis C. Thoracic aortic
aneurysm D. Raynaud disease B. Deep vein thrombosis Although the exact
cause of venous thrombosis remains unclear, three factors, known as Virchow triad,
are believed to play a significant role in its development: stasis of blood (venous
stasis), vessel wall injury, and altered blood coagulation. This client has venous
stasis from immobility, vessel wall injury from PAD, and altered blood coagulation
from HF.
A nurse has written a plan of care for a client diagnosed with peripheral arterial
insufficiency. One of the nursing diagnoses in the care plan is altered peripheral
tissue perfusion related to compromised circulation. Which intervention is the most
appropriate for this diagnosis? A. Elevate the legs and arms above the heart when
resting. B. Encourage the client to engage in a moderate amount of exercise. C.
Encourage extended periods of sitting or standing. D. Discourage walking in order
to limit pain. B. Encourage the client to engage in a moderate amount of
exercise. The nursing diagnosis of altered peripheral tissue perfusion related to
compromised circulation requires interventions that focus on improving circulation.
Encouraging the client to engage in a moderate amount of exercise serves to improve
circulation. Elevating the client's legs and arms above the heart when resting
would be passive and fails to promote circulation. Encouraging long periods of
sitting or standing would further compromise circulation. The nurse should
encourage, not discourage, walking to increase circulation and decrease pain.

The nurse is planning care for a client with venous insufficiency. Which nursing
intervention would be appropriate for this client's plan of care? A. Elevate lower
extremities. B. Educate on decreased protein. C. Apply compression only at night.
D. Teach frequent rest periods due to pain. A. Elevate lower extremities.
Venous insufficiency is lack of blood flow back to the heart. Elevation of lower
extremities will assist the peripheral blood vessels in returning stasis of blood.
Increased protein should be taught. Compression therapy should be used but not only
at night. Pain is not usually assessed in clients with venous insufficiency but
with arterial insufficiency.
The nurse is preparing to administer warfarin to a client with deep vein
thrombophlebitis. Which laboratory value would most clearly indicate that the
client's warfarin is at therapeutic levels? A. Partial thromboplastin time (PTT)
within normal reference range B. Prothrombin time (PT) 8 to 10 times the control
C. International normalized ratio (INR) between 2 and 3 D. Hematocrit of 32%
C. International normalized ratio (INR) between 2 and 3 The INR is most often
used to determine whether warfarin is at a therapeutic level; an INR of 2 to 3 is
considered therapeutic. Warfarin is also considered to be at therapeutic levels
when the client's PT is 1.5 to 2 times the control. Higher values indicate
increased risk of bleeding and hemorrhage, whereas lower values indicate increased
risk of blood clot formation. Heparin, not warfarin, prolongs PTT. Hematocrit does
not provide information on the effectiveness of warfarin; however, a falling
hematocrit in a client taking warfarin may be a sign of hemorrhage.
"The clinic nurse is caring for a 57-year-old client who reports experiencing leg
pain whenever walking several blocks. The client has type 1 diabetes and has smoked
a pack of cigarettes every day for the past 40 years. The health care provider
diagnoses intermittent claudication. The nurse should provide which instruction
about long-term care to the client? A. ""Be sure to practice meticulous foot
care."" B. ""Consider cutting down on your smoking."" C. ""Reduce your activity
level to accommodate your limitations."" D. ""Try to make sure you eat enough
protein.""" "A. ""Be sure to practice meticulous foot care."" The client with
peripheral vascular disease or diabetes should receive education or reinforcement
about skin and foot care. Intermittent claudication and other chronic peripheral
vascular diseases reduce oxygenation to the feet, making them susceptible to injury
and poor healing; therefore, meticulous foot care is essential. The client should
stop smoking not just cut down because nicotine is a vasoconstrictor. Daily walking
benefits the client with intermittent claudication. Increased protein intake will
not alleviate the client's symptoms."
A client who has undergone a femoral to popliteal bypass graft surgery returns to
the surgical unit. Which assessments should the nurse perform during the first
postoperative day? A. Assess pulse of affected extremity every 15 minutes at
first. B. Palpate the affected leg for pain during every assessment C. Assess the
client for signs and symptoms of compartment syndrome every 2 hours. D. Perform
Doppler evaluation once daily. A. Assess pulse of affected extremity
every 15 minutes at first. The primary objective in the postoperative period is to
maintain adequate circulation through the arterial repair. Pulses, Doppler
assessment, color and temperature, capillary refill, and sensory and motor function
of the affected extremity are checked and compared with those of the other
extremity; these values are recorded initially every 15 minutes and then at
progressively longer intervals if the client's status remains stable.
The nurse is caring for a client who is diagnosed with Raynaud phenomenon. The
nurse should plan interventions to address which nursing diagnosis? A. Chronic
pain B. Ineffective tissue perfusion C. Impaired skin integrity D. Risk for injury
B. Ineffective tissue perfusion Raynaud phenomenon is a form of
intermittent arteriolar vasoconstriction resulting in inadequate tissue perfusion.
This results in coldness, pain, and pallor of the fingertips or toes. Pain is
typically intermittent and acute, not chronic, and skin integrity is rarely at
risk. In most cases, the client is not at a high risk for injury.
A client presents to the clinic reporting the inability to grasp objects with the
right hand. The client's right arm is cool and has a difference in blood pressure
of more than 20 mm Hg compared with the left arm. The nurse should expect that the
primary provider may diagnose the client with which health problem? A. Lymphedema
B. Raynaud phenomenon C. Upper extremity arterial occlusive disease D. Upper
extremity venous thromboembolism (VTE) C. Upper extremity arterial
occlusive disease The client with upper extremity arterial occlusive disease
typically complains of arm fatigue and pain with exercise (forearm claudication)
and inability to hold or grasp objects (e.g., combing hair, placing objects on
shelves above the head) and, occasionally, difficulty driving. Assessment findings
include coolness and pallor of the affected extremity, decreased capillary refill,
and a difference in arm blood pressures of more than 20 mm Hg. These symptoms are
not closely associated with Raynaud disease or lymphedema. The upper extremities
are rare sites for VTE.
A nurse working in a long-term care facility is performing the admission assessment
of a newly admitted 85-year-old resident. During inspection of the resident's feet,
the nurse notes early evidence of gangrene on one of the resident's great toes. The
nurse should assess for further evidence of which health problem? A. Chronic
venous insufficiency B. Raynaud phenomenon C. Venous thromboembolism (VTE) D.
Peripheral artery disease (PAD) D. Peripheral artery disease (PAD) In
older adults, symptoms of PAD may be more pronounced than in younger people. In
older adult clients who are inactive, gangrene may be the first sign of disease.
Venous insufficiency does not normally manifest with gangrene.
The nurse is assessing a woman who is pregnant at 27 weeks' gestation. The client
is concerned about the recent emergence of varicose veins on the backs of her
calves. What is the nurse's best action? A. Facilitate a referral to a vascular
surgeon. B. Assess the client's ankle-brachial index (ABI) and perform Doppler
ultrasound testing. C. Encourage the client to increase her activity level. D.
Teach the client that circulatory changes during pregnancy frequently cause
varicose veins. D. Teach the client that circulatory changes during
pregnancy frequently cause varicose veins. Pregnancy may cause varicosities because
of hormonal effects related to decreased venous outflow, increased pressure by the
gravid uterus, and increased blood volume.
"Graduated compression stockings have been prescribed to treat a client's venous
insufficiency. What education should the nurse prioritize when introducing this
intervention to the client? A. The need to take anticoagulants concurrent with
using compression stockings B. The need to wear the stockings on a ""one day on,
one day off"" schedule C. The importance of wearing the stockings around the clock
to ensure maximum benefit D. The importance of ensuring the stockings are applied
evenly with no pressure points" D. The importance of ensuring the
stockings are applied evenly with no pressure points Any type of stocking can
inadvertently become a tourniquet if applied incorrectly (i.e., rolled tightly at
the top). In such instances, the stockings produce rather than prevent stasis. For
ambulatory clients, graduated compression stockings are removed at night and
reapplied before the legs are lowered from the bed to the floor in the morning.
They are used daily, not on alternating days. Anticoagulants are not always
indicated in clients who are using compression stockings.
The nurse caring for a client with a leg ulcer has finished assessing the client
and is developing a problem list prior to writing a plan of care. What priority
risk would the care plan address? A. Disuse syndrome B. Ineffective health
maintenance C. Sedentary lifestyle D. Insufficient nutrition D.
Insufficient nutrition The client with leg ulcers is at risk for insufficient
nutrition related to the increased need for nutrients that promote wound healing.
The risk for disuse syndrome is a state in which an individual is at risk for
deterioration of body systems owing to prescribed or unavoidable musculoskeletal
inactivity. A leg ulcer will affect activity, but rarely to this degree. Leg ulcers
are not necessarily a consequence of ineffective health maintenance or a sedentary
lifestyle.
A client with advanced venous insufficiency is confined to bed rest following
orthopedic surgery. How can the nurse best prevent skin breakdown in the client's
lower extremities? A. Ensure that the client's heels are protected and supported.
B. Closely monitor the client's serum albumin and prealbumin levels. C. Perform
gentle massage of the client's lower legs, as tolerated. D. Perform passive range-
of-motion exercises once per shift. A. Ensure that the client's heels are
protected and supported. If the client is on bed rest, it is important to relieve
pressure on the heels to prevent pressure ulcerations, since the heels are among
the most vulnerable body regions. Monitoring blood work does not directly prevent
skin breakdown, even though albumin is related to wound healing. Massage is not
normally indicated and may exacerbate skin breakdown. Passive range-of-motion
exercises do not directly reduce the risk of skin breakdown.
The nurse has performed a thorough nursing assessment of the care of a client with
chronic leg ulcers. The nurse's assessment should include which of the following
components? SATA A. Location and type of pain B. Apical heart rate C. Bilateral
comparison of peripheral pulses D. Comparison of temperature in the client's legs
E. Identification of mobility limitations A. Location and type of pain C.
Bilateral comparison of peripheral pulses D. Comparison of temperature in the
client's legs E. Identification of mobility limitations A careful nursing history
and assessment are important. The extent and type of pain are carefully assessed,
as are the appearance and temperature of the skin of both legs. The quality of all
peripheral pulses is assessed, and the pulses in both legs are compared.
A postsurgical client has illuminated the call light to inform the nurse of a
sudden onset of lower leg pain. On inspection, the nurse observes that the client's
left leg is visibly swollen and reddened. Which action by the nurse would be most
appropriate? A. Administer a PRN dose of subcutaneous heparin. B. Inform the
health care provider that the client has signs and symptoms of venous
thromboembolism (VTE). C. Mobilize the client promptly to dislodge any thrombi in
the client's lower leg. D. Massage the client's lower leg to temporarily restore
venous return. B. Inform the health care provider that the client has
signs and symptoms of venous thromboembolism (VTE). VTE requires prompt medical
follow-up. Heparin will not dissolve an established clotMassaging the client's leg
and mobilizing the client would be contraindicated because they would dislodge the
clot, possibly resulting in a pulmonary embolism.
A nurse is closely monitoring a client who has recently been diagnosed with an
abdominal aortic aneurysm. What assessment finding would signal an impending
rupture of the client's aneurysm? A. Sudden increase in blood pressure and a
decrease in heart rate B. Cessation of pulsating in an aneurysm that has previously
been pulsating visibly C. Sudden onset of severe back or abdominal pain D. New
onset of hemoptysis C. Sudden onset of severe back or abdominal pain
Signs of impending rupture include severe back or abdominal pain, which may be
persistent or intermittent. Impending rupture is not typically signaled by
increased blood pressure, bradycardia, cessation of pulsing, or hemoptysis.
A nurse is reviewing the physiologic factors that affect a client's cardiovascular
health and tissue oxygenation. What is the systemic arteriovenous oxygen
difference? A. The average amount of oxygen removed by each organ in the body B.
The amount of oxygen removed from the blood by the heart C. The amount of oxygen
returning to the lungs via the pulmonary artery D. The amount of oxygen in aortic
blood minus the amount of oxygen in the vena caval blood D. The amount of
oxygen in aortic blood minus the amount of oxygen in the vena caval blood The
average amount of oxygen removed collectively by all of the body tissues is about
25%. This means that the blood in the vena cava contains about 25% less oxygen than
aortic blood. This is known as the systemic arteriovenous oxygen difference.
The nurse is evaluating a client's diagnosis of arterial insufficiency with
reference to the adequacy of the client's blood flow. On what physiologic variables
does adequate blood flow depend? SATA A. Efficiency of heart as a pump B. Adequacy
of circulating blood volume C. Ratio of platelets to red blood cells D. Size of red
blood cells E. Patency and responsiveness of the blood vessels A.
Efficiency of heart as a pump B. Adequacy of circulating blood volume E. Patency
and responsiveness of the blood vessels Adequate blood flow depends on the
efficiency of the heart as a pump, the patency and responsiveness of the blood
vessels, and the adequacy of circulating blood volume.
A nurse is assessing a new client who is diagnosed with peripheral artery disease.
The nurse cannot feel the pulse in the client's left foot. How should the nurse
proceed with assessment? A. Have the primary care provider prescribe a computed
tomography (CT) scan. B. Apply a tourniquet for 3 to 5 minutes and then reassess.
C. Elevate the extremity and attempt to palpate the pulses. D. Use Doppler
ultrasound to identify the pulses. D. Use Doppler ultrasound to identify the
pulses. When pulses cannot be reliably palpated, a hand-held continuous wave
Doppler ultrasound device may be used to hear (insonate) the blood flow in vessels.

A medical nurse has admitted four clients over the course of a 12-hour shift. For
which client would assessment of ankle-brachial index (ABI) be most clearly
warranted? A. A client who has peripheral edema secondary to chronic heart failure
B. An older adult client who has a diagnosis of unstable angina C. A client with
poorly controlled type 1 diabetes who is a smoker D. A client who has community-
acquired pneumonia and a history of COPD C. A client with poorly controlled
type 1 diabetes who is a smoker Nurses should perform a baseline ABI on any client
with decreased pulses or any client 50 years of age or older with a history of
diabetes or smoking.
A 79-year-old client is admitted to the medical unit with digital gangrene. The
client reports that the problem first began when the client stubbed the toe going
to the bathroom in the dark. In addition to this trauma, the nurse should suspect
that the client has a history of which health problem? A. Raynaud phenomenon B.
Coronary artery disease (CAD) C. Arterial insufficiency D. Varicose veins
C. Arterial insufficiency Arterial insufficiency may result in gangrene of
the toe (digital gangrene), which usually is caused by trauma. The toe is stubbed
and then turns black. Raynaud disease, CAD, and varicose veins are not the usual
causes of digital gangrene in older adults.
When assessing venous disease in a client's lower extremities, the nurse knows that
what test will most likely be prescribed? A. Duplex ultrasonography B.
Echocardiography C. Positron emission tomography (PET) D. Radiography A.
Duplex ultrasonography Duplex ultrasound may be used to determine the level and
extent of venous disease as well as its chronicity.
The nurse is providing care for a client who has just been diagnosed with
peripheral arterial occlusive disease (PAD). What assessment finding is most
consistent with this diagnosis? A. Numbness and tingling in the distal extremities
B. Unequal peripheral pulses between extremities C. Visible clubbing of the
fingers and toes D. Reddened extremities with muscle atrophy B. Unequal
peripheral pulses between extremities PAD assessment may manifest as unequal
pulses between extremities, with the affected leg cooler and paler than the
unaffected leg. Intermittent claudication is far more common than sensations of
numbness and tingling.
A nurse is admitting a client to the medical unit who has a history of peripheral
artery disease (PAD). While providing the health history, the client reports
smoking about two packs of cigarettes a day, having a history of alcohol abuse, and
not exercising. Which topic would be the priority health education for this client?
A. The lack of exercise, which is the main cause of PAD B. The likelihood that
heavy alcohol intake is a significant risk factor for PAD C. The nicotine in
cigarettes, which is a powerful vasoconstrictor and may cause or aggravate PAD D.
Alcohol, which suppresses the immune system, creates high glucose levels, and may
cause PAD C. The nicotine in cigarettes, which is a powerful
vasoconstrictor and may cause or aggravate PAD Tobacco is powerful vasoconstrictor;
its use with PAD is highly detrimental, and clients are strongly advised to stop
using tobacco. Sedentary lifestyle is also a risk factor, but smoking is likely a
more significant risk factor that the nurse should address. Alcohol use is less
likely to cause PAD, although it carries numerous health risks.
A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must
be alert for signs and symptoms of aneurysm rupture and thus looks for which of the
following? A. Constant, intense back pain and falling blood pressure B. Constant,
intense headache and falling blood pressure C. Higher than normal blood pressure
and falling hematocrit D. Slow heart rate and high blood pressure A.
Constant, intense back pain and falling blood pressure Indications of a rupturing
abdominal aortic aneurysm include constant, intense back pain; falling blood
pressure; and decreasing hematocrit.
Which of the following is a diagnostic test that involves injection of a contrast
media into the venous system through a dorsal vein in the foot? A. Contrast
phlebography B. Air plethysmography C. Lymphangiography D. Lymphoscintigraphy
A. Contrast phlebography When a thrombus exists, an X-ray image will disclose
an unfilled segment of a vein. Air plethysmography quantifies venous reflux and
calf muscle pump ejectionLymphangiography, contrast media are injected into the
lymph system. Lymphoscintigraphy, a radioactive-labeled colloid is injected into
the lymph system.
A physician admits a client to the health care facility for treatment of an
abdominal aortic aneurysm. When planning this client's care, which goal should the
nurse keep in mind as she formulates interventions? A. Decreasing blood pressure
and increasing mobility B. Increasing blood pressure and reducing mobility C.
Stabilizing heart rate and blood pressure and easing anxiety D. Increasing blood
pressure and monitoring fluid intake and output C. Stabilizing heart rate and
blood pressure and easing anxiety For a client with an aneurysm, nursing
interventions focus on preventing aneurysm rupture by stabilizing heart rate and
blood pressure. Easing anxiety also is important because anxiety and increased
stimulation may raise the heart rate and boost blood pressure, precipitating
aneurysm rupture. The client with an abdominal aortic aneurysm is typically
hypertensive, so the nurse should take measures to lower blood pressure, such as
administering antihypertensive agents, as ordered, to prevent aneurysm rupture. To
sustain major organ perfusion, the client should maintain a mean arterial pressure
of at least 60 mm Hg. Although the nurse must assess each client's mobility
individually, most clients need bed rest when initially attempting to gain
stability.
A postoperative client is receiving heparin after developing thrombophlebitis. The
nurse monitors the client carefully for bleeding and other adverse effects of
heparin. If the client starts to exhibit signs of excessive bleeding, the nurse
should expect to administer an antidote that is specific to heparin. Which agent
fits this description? A. Phytonadione (vitamin K) B. Protamine sulfate C.
Thrombin D. Plasma protein fraction B. Protamine sulfate Protamine sulfate is
the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific
to oral anticoagulants such as warfarin. Thrombin is a hemostatic agent used to
control local bleeding. Plasma protein fraction, a blood derivative, supplies
colloids to the blood and expands plasma volume; it's used to treat clients who are
in shock.
Health teaching includes advising patients on ways to reduce PAD. The nurse should
always emphasize that the strongest risk factor for the development of
atherosclerotic lesions A. Cigarette smoking. B. Lack of exercise. C. Obesity. D.
Stress. A. Cigarette smoking. Nicotine decreases blood flow, increases
heart rate and blood pressure, and increases the risk for clot formation by
increasing platelet aggregation. Smokers have a four-fold higher risk of developing
pain from arterial disease than nonsmokers.
The most important reason for a nurse to encourage a client with peripheral
vascular disease to initiate a walking program is that this form of exercise: A.
reduces stress. B. aids in weight reduction. C. increases high-density lipoprotein
(HDL) level. D. decreases venous congestion. D. decreases venous
congestion. Regular walking is the best way to decrease venous congestion because
using the leg muscles as a pump helps return blood to the heart. Regular exercise
also aids in stress reduction and weight reduction and increases the formation of
HDLs — which are all beneficial to a client with peripheral vascular disease.

Approximately what percentage of the arterial lumen must be obstructed before

intermittent claudication is experienced? A. 20 B. 30 C. 40 D. 50 D. 50
Typically, about 50% of the arterial lumen or 75% of the cross-sectional area must
be obstructed before intermittent claudication is experienced.
A client with systemic lupus erythematosus (SLE) complains that his hands become
pale, blue, and painful when exposed to the cold. What disease should the nurse
cite as an explanation for these signs and symptoms? A. Peripheral vascular
disease B. Raynaud's disease C. Arterial occlusive diseases D. Buerger's disease
B. Raynaud's disease Raynaud's disease results from reduced blood flow to the
extremities when exposed to cold or stress. It's commonly associated with
connective tissue disorders such as SLE. Signs and symptoms include pallor,
coldness, numbness, throbbing pain, and cyanosis
Which statement is accurate regarding Raynaud disease? A. The disease generally
affects the client trilaterally. B. It affects more than two digits on each hand or
foot. C. It is most common in men 16 to 40 years of age. D. Episodes may be
triggered by unusual sensitivity to cold. D. Episodes may be triggered by
unusual sensitivity to cold. Episodes of Raynaud disease may be triggered by
emotional factors or by unusual sensitivity to cold. The disease is most common in
women between 16 and 40 years of age. It is generally unilateral and affects only
one or two digits.
The nurse is caring for a patient who has started anticoagulant therapy with
warfarin (Coumadin). When does the nurse understand that therapeutic benefits will
begin? A. Within 12 hours B. Within the first 24 hours C. In 2 days D. In 3 to 5
days D. In 3 to 5 days Oral anticoagulants, such as warfarin, are monitored
by the PT or the INR. Because the full anticoagulant effect of warfarin is delayed
for 3 to 5 days, it is usually administered concurrently with heparin until desired
anticoagulation has been achieved
"A community health nurse teaches a group of older adults about modifiable risk
factors that contribute to the development of peripheral arterial disease (PAD).
The nurse knows that the teaching was effective based on which statement? A. ""I
will need to stop smoking because the nicotine causes less blood to flow to my
hands and feet."" B. ""I will need to increase the amount of green leafy vegetables
I eat to lower my cholesterol levels."" C. ""The older I get the higher my risk for
peripheral arterial disease gets."" D. ""Because my family is from Italy, I have a
higher risk of developing peripheral arterial disease.""" "A. ""I will need
to stop smoking because the nicotine causes less blood to flow to my hands and
feet."" The use of tobacco products may be one of the most important risk factors
in the development of atherosclerotic lesions. Nicotine in tobacco decreases blood
flow to the extremities and increases heart rate and blood pressure by stimulating
the sympathetic nervous system. This causes vasoconstriction, thereby decreasing
arterial blood flow. It also increases the risk of clot formation by increasing the
aggregation of platelets."
The nurse is caring for a client with Raynaud's disease. What are important
instructions for a client who is diagnosed with this disease to prevent an attack?
A. Report changes in the usual pattern of chest pain. B. Avoid situations that
contribute to ischemic episodes. C. Avoid fatty foods and exercise. D. Take over-
the-counter decongestants. B. Avoid situations that contribute to ischemic
episodes. Teaching for clients with Raynaud's disease and their family members is
important. The nurse should instruct the clients to avoid situations that
contribute to ischemic episodes. Reporting changes in the usual pattern of chest
pain or avoiding fatty foods and exercise does not help the client to avoid an
attack
A patient is having an angiography to detect the presence of an aneurysm. After the
contrast is administered by the interventionist, the patient begins to complain of
nausea and difficulty breathing. What medication is a priority to administer at
this time? A. Metoprolol (Lopressor) B. Epinephrine C. Hydrocortisone (Solu-
Cortef) D. Cimetidine (Tagamet) B. Epinephrine Infrequently, a patient
may have an immediate or delayed allergic reaction to the iodine contained in the
contrast agent used in angiography. Manifestations include dyspnea, nausea and
vomiting, sweating, tachycardia, and numbness of the extremities. Any such reaction
must be reported to the interventionalist at once --> Treatment may include the
administration of epinephrine, antihistamines, or corticosteroids.
A female client is re-admitted to the facility with a warm, tender, reddened area
on her right calf. Which contributing factor should the nurse recognize as most
important? A. History of increased aspirin use B. Recent pelvic surgery C. An
active daily walking program D. A history of diabetes mellitus B. Recent
pelvic surgery The client shows signs of deep vein thrombosis (DVT). The pelvic
area has a rich blood supply, and thrombophlebitis of the deep veins is associated
with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program
help decrease the client's risk of DVTIn general, diabetes mellitus is a
contributing factor associated with peripheral vascular disease.
The nurse is caring for a patient with venous insufficiency. For what should the
nurse assess the patient's lower extremities? A. Rubor B. Cellulitis C. Dermatitis
D. Ulceration D. Ulceration Venous ulceration is the most serious
complication of chronic venous insufficiency and can be associated with other
conditions affecting the circulation of the lower extremities.
A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism
(VTE). Which laboratory value indicates that anticoagulation is adequate and
enoxaparin can be discontinued? A. Activated partial thromboplastin time (aPPT) is
half of the control value B. Prothrombin time (PT) is 0.5 times normal. C.
International normalized ratio (INR) is 2.5. D. K+ level is 3.5. C.
International normalized ratio (INR) is 2.5. Oral anticoagulants such as warfarin
are monitored by PT or the INR. Because the full anticoagulant effect of warfarin
is delayed for 3 to 5 days, it is usually administered concurrently with heparin
until desired anticoagulation has been achieved
"The nurse is assisting a patient with peripheral arterial disease to ambulate in
the hallway. What should the nurse include in the education of the patient during
ambulation? A. ""As soon as you feel pain, we will go back and elevate your
legs."" B. ""If you feel pain during the walk, keep walking until the end of the
hallway is reached."" C. ""Walk to the point of pain, rest until the pain subsides,
then resume ambulation."" D. ""If you feel any discomfort, stop and we will use a
wheelchair to take you back to your room.""" "C. ""Walk to the point of
pain, rest until the pain subsides, then resume ambulation."" The nurse instructs
the patient to walk to the point of pain, rest until the pain subsides, and then
resume walking so that endurance can be increased as collateral circulation
develops."
A patient who had a colon resection 3 days ago is complaining of discomfort in the
left calf. How should the nurse assess Homan's sign to determine if the patient may
have a thrombus formation in the leg? A. Dorsiflex the foot while the leg is
elevated to check for calf pain. B. Elevate the patient's legs for 20 minutes and
then lower them slowly while checking for areas of inadequate blood return. C.
Extend the leg, plantar flex the foot, and check for the patency of the dorsalis
pedis pulse. D. Lower the patient's legs and massage the calf muscles to note any
areas of tenderness. A. Dorsiflex the foot while the leg is elevated to
check for calf pain. Homan's sign is indicated by pain in the calf after the foot
is sharply dorsiflexed.
A client with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower
back pain. Which is the most likely cause? A. The aneurysm has become obstructed.
B. The aneurysm may be preparing to rupture. C. The client is experiencing
inflammation of the aneurysm. D. The client is experiencing normal sensations
associated with this condition. B. The aneurysm may be preparing to
rupture. Signs of impending rupture include severe back or abdominal pain, which
may be persistent or intermittent. Indications of a rupturing AAA include constant,
intense back pain; falling blood pressure; and decreasing hematocrit. Abdominal
pain is often localized to the middle or lower abdomen to the left of the midline.
Low-back pain may be present because of pressure of the aneurysm on the lumbar
nerves. Rupture into the peritoneal cavity is quickly fatal. A retroperitoneal
rupture of an aneurysm may result in hematomas in the scrotum, perineum, flank, or
penis.
Heparin therapy is usually considered therapeutic when the activated partial
thromboplastin time (aPTT) is how many times higher than a normal value? A. 0.5 to
1.5 B. 1.5 to 2.5 C. 2.5 to 3.5 D. 3.5 to 4.5 B. 1.5 to 2.5 Heparin therapy
is usually considered therapeutic when the aPTT is 1.5 to 2.5 times the normal aPTT
value.
On a routine visit to the physician, a client with chronic arterial occlusive
disease reports that he's stopped smoking after 34 years. To relieve symptoms of
intermittent claudication, a condition associated with chronic arterial occlusive
disease, which additional measure should the nurse recommend? A. Taking daily
walks B. Engaging in anaerobic exercise C. Reducing daily fat intake to less than
45% of total calories D. Abstaining from foods that increase levels of high-density
lipoproteins (HDLs) A. Taking daily walks Taking daily walks relieves
symptoms of intermittent claudication, although the exact mechanism is unclear.
Anaerobic exercise may make these symptoms worse. Clients with chronic arterial
occlusive disease must reduce daily fat intake to 30% or less of total calories.
The client should limit dietary cholesterol because hyperlipidemia is associated
with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs
have the lowest cholesterol concentration, so this client should eat, not abstain
from, foods that raise HDL levels.
"A client admitted to the medical-surgical unit with a venous thromboembolism (VTE)
is started on enoxaparin and warfarin. The client asks the nurse why two
medications are needed. Which response by the nurse is accurate? A.
""Administration of two anticoagulants decreases the risk of recurrent venous
thrombosis."" B. ""Enoxaparin will 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 achieve its full effect."" D. ""Because of the
potential for a pulmonary embolism, it is important for you to take at least two
anticoagulants.""" "C. ""The enoxaparin will work immediately, but the
warfarin takes several days to achieve its full effect."" Oral anticoagulants such
as warfarin are monitored by the prothrombin time (PT) or the international
normalized ratio (INR). Because the full anticoagulant effect of warfarin is
delayed for 3 to 5 days, it is usually administered concurrently with heparin until
desired anticoagulation has been achieved"
A home health nurse is seeing an elderly female client for the first time. During
the physical assessment of the client's feet, the nurse notes several circular
ulcers around the tips of the toes on both feet. The bases of the ulcers are pale,
and the client reports the ulcers to be very painful. From these assessment
findings, the nurse suspects that the cause of the ulcers is which of the
following? A. Arterial insufficiency B. Venous insufficiency C. Neither venous nor
arterial D. Trauma A. Arterial insufficiency Characteristics of arterial
insufficiency ulcers include location at the tips of the toes, extreme painfulness,
and circular shape with pale to black ulcer bases. Ulcers caused by venous
insufficiency will be irregular in shape, minimal pain if superficial (can be
painful), and usually located around the ankles or the anterior tibial area.
A client reports pain and cramping in the thigh when climbing stairs and numbness
in the legs after exertion. Which diagnostic test with the physician likely perform
right in the office to determine PAD? A. ankle-brachial index B. exercise
electrocardiography C. electron beam computed tomography (EBCT) D.
photoplethysmography A. ankle-brachial index The client's symptoms
indicate possible peripheral artery disease (PAD). The ankle-brachial index is a
simple, noninvasive test used for this diagnosis. An exercise electrocardiography
may be ordered for a client with possible CAD. An EBCT is a radiologic test that
produces x-rays of the coronary arteries using an electron beam. It is used to
diagnose for CAD. Clients with suspected venous insufficiency will undergo
photoplethysmography, a diagnostic test that measures light that is not absorbed by
hemoglobin and consequently is reflected back to the machine.
Pentoxifylline (Trental) is a medication used for which of the following
conditions? A. Claudication B. Thromboemboli C. Hypertension D. Elevated
triglycerides A. Claudication Trental and Pletal are the only medications
specifically indicated for the treatment of claudication. Thromboemboli,
hypertension, and elevated triglycerides are not indications for using Trental.

The most common site of aneurysm formation is in the: A. abdominal aorta, just
below the renal arteries. B. ascending aorta, around the aortic arch. C. descending
aorta, beyond the subclavian arteries. D. aortic arch, around the ascending and
descending aorta. A. abdominal aorta, just below the renal arteries. About
75% of aneurysms occur in the abdominal aorta, just below the renal arteries -->
Debarked type I aneurysms Debarked type II aneurysms occur in the aortic arch
around the ascending and descending aortaDebarked type III aneurysms occur in the
descending aorta, beyond the subclavian arteries.
Which of the following are alterations noted in Virchow's triad? SATA A. Stasis of
blood B. Vessel wall injury C. Altered coagulation D. Edema E. Tenderness
A. Stasis of blood B. Vessel wall injury C. Altered coagulation Three
factors, known as Virchow's triad, are believed to play a significant role in the
development of venous thrombosis. They are stasis of blood, vessel wall injury, and
altered coagulation.
While receiving heparin to treat a pulmonary embolus, a client passes bright red
urine. What should the nurse do first? A. Decrease the heparin infusion rate. B.
Prepare to administer protamine sulfate. C. Monitor the partial thromboplastin time
(PTT). D. Start an I.V. infusion of dextrose 5% in water (D5W). B. Prepare
to administer protamine sulfate. Frank hematuria indicates excessive
anticoagulation and bleeding — and heparin overdose. The nurse should discontinue
the heparin infusion immediately and prepare to administer protamine sulfate, the
antidote for heparin. Decreasing the heparin infusion rate wouldn't prevent further
bleeding. Although the nurse should continue to monitor PTT, this action should
occur later. An I.V. infusion of D5W may be administered, but only after protamine
has been given.
Which of the following are indications of a rupturing aortic aneurysm? SATA A.
Constant, intense back pain B. Decreasing blood pressure C. Decreasing hematocrit
D. Increasing blood pressure E. Increasing hematocrit A. Constant, intense
back pain B. Decreasing blood pressure --> hypotension C. Decreasing hematocrit
Indications of a rupturing abdominal aneurysm include constant, intense back pain;
falling blood pressure; and decreasing hematocrit.
"A nurse is teaching a client who will soon be discharged with a prescription for
warfarin (Coumadin). Which statement should the nurse include in discharge
teaching? A. ""Eat more yogurt and broccoli."" B. ""This drug will dissolve any
clots you may still have."" C. ""If you miss a dose, double the next dose."" D.
""Don't take aspirin while you're taking warfarin.""" "D. ""Don't take aspirin
while you're taking warfarin."" Because aspirin decreases platelet aggregation and
interferes with clotting, concomitant use of aspirin with warfarin, an
anticoagulant, may lead to excessive anticoagulant effects — and bleeding.
Increase intake of foods rich in vitamin K, such as broccoli, could change the
client's warfarin dose requirements. Although warfarin interrupts the normal
clotting cycle, it doesn't dissolve clots that have already formed. The client
should take warfarin exactly as ordered to maintain the desired level of
anticoagulation. Doubling a dose could cause bleeding."
"Two days after undergoing a total abdominal hysterectomy, a client complains of
left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this
client, the nurse is likely to detect: A. pallor and coolness of the left foot. B.
a decrease in the left pedal pulse. C. loss of hair on the lower portion of the
left leg. D. left calf circumference 1"" (2.5 cm) larger than the right."
"D. left calf circumference 1"" (2.5 cm) larger than the right. Signs of DVT
include inflammation and edema in the affected extremity, causing its circumference
to exceed that of the opposite extremity. Pallor, coolness, decreased pulse, and
hair loss in an extremity signals interrupted arterial blood flow, which doesn't
occur in DVT."
The nurse knows which diagnostic test is used to document the anatomic site of
reflux and provides a quantitative measure of the severity of valvular reflux? A.
Contrast phlebography B. Duplex ultrasound scan C. Lymphangiography D.
Lymphoscintigraphy B. Duplex ultrasound scan Diagnostic tests for
varicose veins include the duplex ultrasound scan, which documents the anatomic
site of reflux and provides a quantitative measure of the severity of valvular
reflux. Contrast phlebography involves injecting a radiopaque contrast agent into
the venous system. Lymphoscintigraphy is done when a radioactively labeled colloid
is injected subcutaneously in the second interdigital space. The extremity is then
exercised to facilitate the uptake of the colloid by the lymphatic system, and
serial images are obtained at preset intervals. Lymphangiography provides a way to
detect lymph node involvement resulting from metastatic carcinoma, lymphoma, or
infection in sites that are otherwise inaccessible to the examiner except by
surgery.
The nurse assesses a patient with hip pain related to intermittent claudication.
She knows that the area of arterial narrowing is the: A. Common iliac artery. B.
Common femoral artery. C. Anterior tibial. D. Posterior tibial. A. Common
iliac artery. The location of the claudication occurs in muscle groups distal to
the diseased vessel. Hip or buttock pain may result from reduced blood flow from
the common iliac artery.
"A client in the emergency department states, ""I have always taken a morning walk,
but lately my leg cramps hurts after just a few minutes of walking. The pain goes
away after I stop walking, though."" Based on this statement, which priority
assessment should the nurse complete? A. Check for the presence of tortuous veins
bilaterally on the legs. B. Ask about any changes in skin color that occur in
response to cold. C. Attempt to palpate the dorsalis pedis and posterior tibial
pulses. D. Assess for unilateral swelling and tenderness of either leg."
C. Attempt to palpate the dorsalis pedis and posterior tibial pulses.
Intermittent claudication is a sign of peripheral arterial insufficiency. The nurse
should assess for other clinical manifestations of peripheral arterial disease in a
client who describes intermittent claudication. A thorough assessment of the
client's skin color and temperature and the character of the peripheral pulses are
important in the diagnosis of arterial disorders.
A client is diagnosed with peripheral arterial disease. Review of the client's
chart shows an ankle-brachial index (ABI) on the right of 0.45. This indicates that
the right foot has which of the following? A. Moderate to severe arterial
insufficiency B. No arterial insufficiency C. Very mild arterial insufficiency D.
Tissue loss to that foot A. Moderate to severe arterial insufficiency
Normal people without arterial insufficiency have an ABI of about 1.0. Those with
an ABI of 0.95 to 0.5 have mild to moderate arterial insufficiencyThose with an ABI
of less than 0.50 have ischemic rest pain. Those with tissue loss have severe
ischemia and an ABI of 0.25 or less.
Which aneurysm occurs as a result of infection at arterial suture or graft sites?
A. Anastomotic B. False C. Dissecting D. Saccular A. Anastomotic An
anastomotic aneurysm occurs as a result of infection, arterial wall failure, and
suture or graft failure. Dissection results from a rupture in the intimal layer,
resulting in bleeding between the intimal and medial layers of the arterial wall.
Saccular aneurysms collect blood in the weakened outpouching. In a false aneurysm,
the mass is actually a pulsating hematoma.
A nurse and physician are preparing to visit a hospitalized client with perepheral
arterial disease. As you approach the client's room, the physician asks if the
client has reported any intermittent claudication. The client has reported this
symptom. The nurse explains to the physician which of the following details? A.
The client can walk about 50 feet before getting pain in the right lower leg. B.
The client's fingers tingle when left in one position for too long. C. The client
experiences shortness of breath after walking about 50 feet. D. The client's legs
awaken him during the night with itching. A.The client can walk about 50 feet
before getting pain in the right lower leg. Intermittent claudication is caused by
the inability of the arterial system to provide adequate blood flow to the tissues
when increased demands are made for oxygen and nutrients during exercise. Pain is
then experienced. When the client rests and decreases demands, the pain subsides.
The client can then walk the same distance and repeat the process.
You are presenting a workshop at the senior citizens center about how the changes
of aging predisposes clients to vascular occlusive disorders. What would you name
as the most common cause of peripheral arterial problems in the older adult? A.
Aneurysm B. Coronary thrombosis C. Atherosclerosis D. Raynaud's disease
C. Atherosclerosis Atherosclerosis is the most common cause of peripheral
arterial problems in the older adult. Therefore, options A, B, and D are incorrect.
A client has been diagnosed with peripheral arterial occlusive disease. Which of
the following instructions is appropriate for the nurse to give the client for
promoting circulation to the extremities? A. Keep the extremities elevated
slightly. B. Participate in a regular walking program. C. Use a heating pad to
promote warmth. D. Massage the calf muscles if pain occurs. B.
Participate in a regular walking program. Clients diagnosed with peripheral
arterial occlusive disease should be encouraged to participate in a regular walking
program to help develop collateral circulation. They should be advised to rest if
pain develops and to resume activity when pain subsides. Extremities should be
kept in a dependent position to promote circulation; elevation of the extremities
will decrease circulation.Heating pads should not be used by anyone with impaired
circulation to avoid burns. Massaging the calf muscles will not decrease pain.
Intermittent claudication subsides with rest.
Which of the following is the most common site for a dissecting aneurysm? A.
Thoracic area B. Lumbar area C. Sacral area D. Cervical area A. Thoracic
area The thoracic area is the most common site for a dissecting aneurysm. About
one-third of patients with thoracic aneurysms die of rupture of the aneurysm.

A patient is suspected to have a thoracic aortic aneurysm. What diagnostic tests

does the nurse anticipate preparing the patient for? SATA A. Computed tomography
B. Transesophageal echocardiography C. X-ray D. Electroencephalogram E.
Electrocardiogram (ECG) A. Computed tomography B. Transesophageal
echocardiography C. X-ray Diagnosis of a thoracic aortic aneurysm is principally
made by chest x-ray, computed tomography angiography (CTA), and transesophageal
echocardiography (TEE).
A physician admits a client to the health care facility for treatment of an
abdominal aortic aneurysm. When planning this client's care, which goal should the
nurse keep in mind as she formulates interventions? A. Decreasing blood pressure
and increasing mobility B. Increasing blood pressure and reducing mobility C.
Stabilizing heart rate and blood pressure and easing anxiety D. Increasing blood
pressure and monitoring fluid intake and output C. Stabilizing heart rate and
blood pressure and easing anxiety For a client with an aneurysm, nursing
interventions focus on preventing aneurysm rupture by stabilizing heart rate and
blood pressure. Easing anxiety also is important because anxiety and increased
stimulation may raise the heart rate and boost blood pressure, precipitating
aneurysm rupture. The client with an abdominal aortic aneurysm is typically
hypertensive, so the nurse should take measures to lower blood pressure, such as
administering antihypertensive agents, as ordered, to prevent aneurysm rupture. To
sustain major organ perfusion, the client should maintain a mean arterial pressure
of at least 60 mm Hg. Although the nurse must assess each client's mobility
individually, most clients need bed rest when initially attempting to gain
stability.
A client who underwent total hip replacement exhibits a red, painful area on the
calf of the affected leg. What test validates presence of thromboembolism? A.
Romberg's B. Phalen's C. Rinne D. Homans' D. Homans' A positive Homans'
sign, or pain in the calf elicited upon flexion of the ankle with the leg straight,
indicates the presence of a thrombus. Testing for Romberg's sign assesses
cerebellar function. Phalen's test assesses carpal tunnel syndrome. The Rinne test
compares air and bone conduction in both ears to screen for or confirm hearing
loss.
A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must
be alert for signs and symptoms of aneurysm rupture and thus looks for which of the
following? A. Constant, intense back pain and falling blood pressure B. Constant,
intense headache and falling blood pressure C. Higher than normal blood pressure
and falling hematocrit D. Slow heart rate and high blood pressure A.
Constant, intense back pain and falling blood pressure Indications of a rupturing
abdominal aortic aneurysm include constant, intense back pain; falling blood
pressure; and decreasing hematocrit.
A postoperative client is receiving heparin after developing thrombophlebitis. The
nurse monitors the client carefully for bleeding and other adverse effects of
heparin. If the client starts to exhibit signs of excessive bleeding, the nurse
should expect to administer an antidote that is specific to heparin. Which agent
fits this description? A. Phytonadione (vitamin K) B. Protamine sulfate C.
Thrombin D. Plasma protein fraction B. Protamine sulfate Protamine
sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the
antidote specific to oral anticoagulants such as warfarin. Thrombin is a hemostatic
agent used to control local bleeding. Plasma protein fraction, a blood derivative,
supplies colloids to the blood and expands plasma volume; it's used to treat
clients who are in shock.
A physician orders blood coagulation tests to evaluate a client's blood-clotting
ability. The nurse knows that such tests are important in assessing clients at risk
for thrombi, such as those with a history of atrial fibrillation, infective
endocarditis, prosthetic heart valves, or myocardial infarction. Which test
determines a client's response to oral anticoagulant drugs? A. Bleeding time B.
Platelet count C. Prothrombin time (PT) D. Partial thromboplastin time (PTT)
C. Prothrombin time (PT) PT determines a client's response to oral
anticoagulant therapy. This test measures the time required for a fibrin clot to
form in a citrated plasma sample following addition of calcium ions and tissue
thromboplastin and compares this time with the fibrin-clotting time in a control
sample. PTT determines the effectiveness of heparin therapy and helps physicians
evaluate bleeding tendencies.
Which sign or symptom suggests that a client's abdominal aortic aneurysm is
extending? A. Increased abdominal and back pain B. Decreased pulse rate and blood
pressure C. Retrosternal back pain radiating to the left arm D. Elevated blood
pressure and rapid respirations A. Increased abdominal and back pain
Pain in the abdomen and back signify that the aneurysm is pressing downward on the
lumbar nerve root and is causing more pain. The pulse rate would increase with
aneurysm extension.
Which aneurysm results in bleeding into the layers of the arterial wall? A.
Saccular B. Dissecting C. False D. Anastomotic B. Dissecting
Dissection results from a rupture in the intimal layer, resulting in bleeding
between the intimal and medial layers of the arterial wall. Saccular aneurysms
collect blood in the weakened outpouching. In a false aneurysm, the mass is
actually a pulsating hematoma. An anastomotic aneurysm occurs as a result of
infection at arterial suture or graft sites.
On a routine visit to the physician, a client with chronic arterial occlusive
disease reports that he's stopped smoking after 34 years. To relieve symptoms of
intermittent claudication, a condition associated with chronic arterial occlusive
disease, which additional measure should the nurse recommend? A. Taking daily
walks B. Engaging in anaerobic exercise C. Reducing daily fat intake to less than
45% of total calories D. Abstaining from foods that increase levels of high-
density lipoproteins (HDLs) A. Taking daily walks Taking daily walks
relieves symptoms of intermittent claudication, although the exact mechanism is
unclear. Anaerobic exercise may make these symptoms worse. Clients with chronic
arterial occlusive disease must reduce daily fat intake to 30% or less of total
calories. The client should limit dietary cholesterol because hyperlipidemia is
associated with atherosclerosis, a known cause of arterial occlusive disease.
However, HDLs have the lowest cholesterol concentration, so this client should eat,
not abstain from, foods that raise HDL levels.
"A client complains of leg pain brought on by walking several blocks, a symptom
that first arose several weeks earlier. The client's history includes diabetes
mellitus and a two-pack-per-day cigarette habit for the past 42 years. The
physician diagnoses intermittent claudication and orders pentoxifylline (Trental),
400 mg three times daily with meals. Which instruction concerning long-term care
should the nurse provide? A. ""Practice meticulous foot care."" B. ""Consider
cutting down on your smoking."" C. ""Reduce your level of exercise."" D. ""See
the physician if complications occur.""" "A. ""Practice meticulous foot
care."" Intermittent claudication and other chronic peripheral vascular diseases
reduce oxygenation to the feet, making them susceptible to injury and poor healing.
Therefore, meticulous foot care is essential. The nurse should teach the client to
bathe his feet in warm water and dry them thoroughly, cut the toenails straight
across, wear well-fitting shoes, and avoid taking medications without the approval
of a physician. Because nicotine is a vasoconstrictor, this client should stop
smoking, not just consider cutting down. Daily walking is beneficial to clients
with intermittent claudication. To evaluate the effectiveness of the therapeutic
regimen, this client should see the physician regularly, not just when
complications occur."
A client is recovering from surgical repair of a dissecting aortic aneurysm. Which
assessment findings indicate possible bleeding or recurring dissection? A. Urine
output of 15 ml/hour and 2+ hematuria B. Blood pressure of 82/40 mm Hg and heart
rate of 125 beats/minute C. Urine output of 150 ml/hour and heart rate of 45
beats/minute D. Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute
B. Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute
Assessment findings that indicate possible bleeding or recurring dissection include
hypotension with reflex tachycardia (as evidenced by a blood pressure of 82/40 mm
Hg and a heart rate of 125 beats/minute), decreased urine output, and unequal or
absent peripheral pulses.
When administering heparin anticoagulant therapy, the nurse needs to make certain
that the activated partial thromboplastin time (aPTT) is within the therapeutic
range of? A. 1.5 to 2.5 times the baseline control. B. 2.5 to 3.0 times the
baseline control. C. 3.5 times the baseline control. D. 4.5 times the baseline
control. A. 1.5 to 2.5 times the baseline control. A normal PTT level is
21 to 35 seconds. A reading of more than 100 seconds indicates a significant risk
of hemorrhage.
A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must
be alert for signs and symptoms of aneurysm rupture and thus looks for which of the
following? A. Constant, intense back pain and falling blood pressure B. Constant,
intense headache and falling blood pressure C. Higher than normal blood pressure
and falling hematocrit D. Slow heart rate and high blood pressure A.
Constant, intense back pain and falling blood pressure Indications of a rupturing
abdominal aortic aneurysm include constant, intense back pain; falling blood
pressure; and decreasing hematocrit.
A client with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower
back pain. Which is the most likely cause? A. The aneurysm has become obstructed.
B. The aneurysm may be preparing to rupture. C. The client is experiencing
inflammation of the aneurysm. D. The client is experiencing normal sensations
associated with this condition. B. The aneurysm may be preparing to
rupture. Signs of impending rupture include severe back or abdominal pain, which
may be persistent or intermittent. Indications of a rupturing AAA include constant,
intense back pain; falling blood pressure; and decreasing hematocrit. Abdominal
pain is often localized to the middle or lower abdomen to the left of the midline.
Low-back pain may be present because of pressure of the aneurysm on the lumbar
nerves. Rupture into the peritoneal cavity is quickly fatal. A retroperitoneal
rupture of an aneurysm may result in hematomas in the scrotum, perineum, flank, or
penis.
A patient is having an angiography to detect the presence of an aneurysm. After the
contrast is administered by the interventionist, the patient begins to complain of
nausea and difficulty breathing. What medication is a priority to administer at
this time? A. Metoprolol (Lopressor) B. Epinephrine C. Hydrocortisone (Solu-
Cortef) D. Cimetidine (Tagamet) B. Epinephrine Infrequently, a patient
may have an immediate or delayed allergic reaction to the iodine contained in the
contrast agent used in angiography. Manifestations include dyspnea, nausea and
vomiting, sweating, tachycardia, and numbness of the extremities. Any such reaction
must be reported to the interventionalist at once --> Treatment may include the
administration of epinephrine, antihistamines, or corticosteroids.
The nurse assesses a patient with hip pain related to intermittent claudication.
She knows that the area of arterial narrowing is the: A. Common iliac artery. B.
Common femoral artery. C. Anterior tibial. D. Posterior tibial. A.
Common iliac artery. The location of the claudication occurs in muscle groups
distal to the diseased vessel. Hip or buttock pain may result from reduced blood
flow from the common iliac artery.
The most common site of aneurysm formation is in the: A. abdominal aorta, just
below the renal arteries. B. ascending aorta, around the aortic arch. C.
descending aorta, beyond the subclavian arteries. D. aortic arch, around the
ascending and descending aorta. A. abdominal aorta, just below the renal
arteries. About 75% of aneurysms occur in the abdominal aorta, just below the renal
arteries --> Debarked type I aneurysms Debarked type II aneurysms occur in the
aortic arch around the ascending and descending aortaDebarked type III aneurysms
occur in the descending aorta, beyond the subclavian arteries.
Which of the following are indications of a rupturing aortic aneurysm? SATA A.
Constant, intense back pain B. Decreasing blood pressure C. Decreasing hematocrit
D. Increasing blood pressure E. Increasing hematocrit A. Constant,
intense back pain B. Decreasing blood pressure C. Decreasing hematocrit
Indications of a rupturing abdominal aneurysm include constant, intense back pain;
falling blood pressure; and decreasing hematocrit.
Which assessment finding by the nurse is the most significant finding suggestive of
aortic aneurysm? A. High blood pressure B. Severe back pain C. Abdomen bruit D.
Nausea and vomiting C. Abdomen bruit A pulsating mass or a bruit in the
abdomen over the mass is most suggestive of aortic aneurysm. Severe back pain,
nausea, and high blood pressure are all symptoms associated with aortic aneurysm
but not as independently suggestive.