1. The nurse is taking a health history of a new patient. The patient
reports experiencing pain in his left lower leg and foot when walking.
This pain is relieved with rest. The nurse notes that the left lower
leg is slightly edematous and is hairless. When planning this
patient’s subsequent care, the nurse should most likely address what
health problem?
A) Coronary artery disease (CAD)
B)
Intermittent claudication
C) Arterial embolus
D) Raynaud’s disease
Ans: B
Feedback:
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 patients 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. The nurse
would not suspect the patient has CAD, arterial embolus, or Raynaud’s
disease; none of these health problems produce this cluster of signs
and symptoms.
2. While assessing a patient the nurse notes that the patient’s
ankle-brachial index (ABI) of the right leg is 0.40. How should the
nurse best respond to this assessment finding?
A) Assess the
patient’s use of over-the-counter dietary supplements.
B)
Implement interventions relevant to arterial narrowing.
C)
Encourage the patient to increase intake of foods high in vitamin
K.
D) Adjust the patient’s activity level to accommodate
decreased coronary output.
Ans: B
Feedback:
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. There is no direct indication for changes
in vitamin K intake and OTC medications are not likely causative.
3. The nurse is providing care for a patient 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
Ans: B
Feedback:
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. Clubbing and muscle atrophy
are not associated with PAD.
4. The nurse is admitting a 32-year-old woman to the presurgical
unit. The nurse learns during the admission assessment that the
patient takes oral contraceptives. Consequently, 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 patient’s extremities when at rest
Ans: A
Feedback:
Oral contraceptive use increases blood
coagulability; with bed rest, the patient may be at increased risk of
developing deep vein thrombosis. Leg exercises and early ambulation
are among the interventions that address this risk. Assessment of
peripheral circulation is important, but Doppler ultrasound may not be
necessary to obtain these data. Dependent positioning increases the
risk of venous thromboembolism (VTE). Contraceptives are not normally
discontinued to address the risk of VTE in the short term.
5. A nurse is creating an education plan for a patient with venous
insufficiency. What measure should the nurse include in the
plan?
A) Avoiding tight-fitting socks.
B) Limit activity
whenever possible.
C) Sleep with legs in a dependent
position.
D) Avoid the use of pressure stockings.
Ans: A
Feedback:
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.
6. The nurse is caring for a patient with a large venous leg ulcer.
What intervention should the nurse implement to promote healing and
prevent infection?
A) Provide a high-calorie, high-protein
diet.
B) Apply a clean occlusive dressing once daily and whenever
soiled.
C) Irrigate the wound with hydrogen peroxide once
daily.
D) Apply an antibiotic ointment on the surrounding skin
with each dressing change.
Ans: A
Feedback:
Wound healing is highly dependent on
adequate nutrition. The diet should be sufficiently high in calories
and protein. Antibiotic ointments are not normally used on the skin
surrounding a leg ulcer and occlusive dressings can exacerbate
impaired blood flow. Hydrogen peroxide is not normally used because it
can damage granulation tissue.
7. The nurse is caring for a patient who returned from the tropics a
few weeks ago and who sought care with signs and symptoms of
lymphedema. The nurse’s plan of care should prioritize what nursing
diagnosis?
A) Risk for infection related to lymphedema
B)
Disturbed body image related to lymphedema
C) Ineffective health
maintenance related to lymphedema
D) Risk for deficient fluid
volume related to lymphedema
Ans: A
Feedback:
Lymphedema, which is caused by
accumulation of lymph in the tissues, constitutes a significant risk
for infection. The patient’s body image is likely to be disturbed, and
the nurse should address this, but infection is a more significant
threat to the patient’s physiological well-being. Lymphedema is
unrelated to ineffective health maintenance and deficient fluid volume
is not a significant risk.
8. An occupational health nurse is providing an educational event and
has been asked by an administrative worker about the risk of varicose
veins. What should the nurse suggest as a proactive preventative
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.
Ans: B
Feedback:
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 patients 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 patients 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.
9. A patient comes to the walk-in clinic with complaints of pain in
his foot following stepping on a roofing nail 4 days ago. The patient
has a visible red streak running up his foot and ankle. What health
problem should the nurse suspect?
A) Cellulitis
B) Local
inflammation
C) Elephantiasis
D) Lymphangitis
Ans: D
Feedback:
Lymphangitis is an acute inflammation of
the lymphatic channels. It arises most commonly from a focus of
infection in an extremity. Usually, the infectious organism is
hemolytic streptococcus. The characteristic red streaks that extend up
the arm or the leg from an infected wound outline the course of the
lymphatic vessels as they drain. Cellulitis is caused by bacteria,
which cause a generalized edema in the subcutaneous tissues
surrounding the affected area. Local inflammation would not present
with red streaks in the lymphatic channels. Elephantiasis is
transmitted by mosquitoes that carry parasitic worm larvae; the
parasites obstruct the lymphatic channels and results in gross
enlargement of the limbs.
10. The triage nurse in the ED is assessing a patient who has
presented with complaint of pain and swelling in her right lower leg.
The patient’s pain became much worse last night and appeared along
with fever, chills, and sweating. The patient states, “I hit my leg on
the car door 4 or 5 days ago and it has been sore ever since.” The
patient has a history of chronic venous insufficiency. What
intervention should the nurse anticipate for this patient?
A)
Platelet transfusion to treat thrombocytopenia
B) Warfarin to
treat arterial insufficiency
C) Antibiotics to treat
cellulitis
D) Heparin IV to treat VTE
Ans: C
Feedback:
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. The patient may be
able to identify a trauma that accounts for the source of infection.
Thrombocytopenia is a loss or decrease in platelets and increases a
patient’s risk of bleeding; this problem would not cause these
symptoms. Arterial insufficiency would present with ongoing pain
related to activity. This patient does not have signs and symptoms of VTE.
11. A nurse in a long-term care facility is caring for an 83-year-old
woman who has a history of HF and peripheral arterial disease (PAD).
At present the patient is unable to stand or ambulate. The nurse
should implement measures to prevent what complication?
A)
Aoritis
B) Deep vein thrombosis
C) Thoracic aortic
aneurysm
D) Raynaud’s disease
Ans: B
Feedback:
Although the exact cause of venous
thrombosis remains unclear, three factors, known as Virchow’s triad,
are believed to play a significant role in its development: stasis of
blood (venous stasis), vessel wall injury, and altered blood
coagulation. In this woman’s case, she has venous stasis from
immobility, vessel wall injury from PAD, and altered blood coagulation
from HF. The cause of aoritis is unknown, but it has no direct
connection to HF, PAD, or mobility issues. The greatest risk factors
for thoracic aortic aneurysm are atherosclerosis and hypertension;
there is no direct connection to HF, PAD, or mobility issues.
Raynaud’s disease is a disorder that involves spasms of blood vessels
and, again, no direct connection to HF, PAD, or mobility issues.
12. A nurse is admitting a 45-year-old man to the medical unit who
has a history of PAD. While providing his health history, the patient
reveals that he smokes about two packs of cigarettes a day, has a
history of alcohol abuse, and does not exercise. What would be the
priority health education for this patient?
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)
Cigarettes contain nicotine, which is a powerful vasoconstrictor and
may cause or aggravate PAD.
D) Alcohol suppresses the immune
system, creates high glucose levels, and may cause PAD.
Ans: C
Feedback:
Tobacco is powerful vasoconstrictor; its
use with PAD is highly detrimental, and patients 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.
13. A nurse has written a plan of care for a man diagnosed with
peripheral arterial insufficiency. One of the nursing diagnoses in the
care plan is altered peripheral tissue perfusion related to
compromised circulation. What is the most appropriate intervention for
this diagnosis?
A) Elevate his legs and arms above his heart when
resting.
B) Encourage the patient to engage in a moderate amount
of exercise.
C) Encourage extended periods of sitting or
standing.
D) Discourage walking in order to limit pain.
Ans: B
Feedback:
The nursing diagnosis of altered
peripheral tissue perfusion related to compromised circulation
requires interventions that focus on improving circulation.
Encouraging the patient to engage in a moderate amount of exercise
serves to improve circulation. Elevating his legs and arms above his
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.
14. The nurse is caring for a 72-year-old patient who is in cardiac
rehabilitation following heart surgery. The patient has been walking
on a regular basis for about a week and walks for 15 minutes 3 times a
day. The patient states that he is having a cramp-like pain in the
legs every time he walks and that the pain gets “better when I rest.”
The patient’s care plan should address what problem?
A) Decreased
mobility related to VTE
B) Acute pain related to intermittent
claudication
C) Decreased mobility related to venous
insufficiency
D) Acute pain related to vasculitis
Ans: B
Feedback:
Intermittent claudication presents as a
muscular, cramp-type pain in the extremities consistently reproduced
with the same degree of exercise or activity and relieved by rest.
Patients with peripheral arterial insufficiency often complain of
intermittent claudication due to a lack of oxygen to muscle tissue.
Venous insufficiency presents as a disorder of venous blood reflux and
does not present with cramp-type pain with exercise. Vasculitis is an
inflammation of the blood vessels and presents with weakness, fever,
and fatigue, but does not present with cramp-type pain with exercise.
The pain associated with VTE does not have this clinical presentation.
15. A nurse in the rehabilitation unit is caring for an older adult
patient who is in cardiac rehabilitation following an MI. The nurse’s
plan of care calls for the patient to walk for 10 minutes 3 times a
day. The patient questions the relationship between walking and heart
function. How should the nurse best reply?
A) “The arteries in
your legs constrict when you walk and allow the blood to move faster
and with more pressure on the tissue.”
B) Walking increases your
heart rate and blood pressure. Therefore your heart is under less
stress.”
C) “Walking helps your heart adjust to your new arteries
and helps build your self-esteem.”
D) “When you walk, the muscles
in your legs contract and pump the blood in your veins back toward
your heart, which allows more blood to return to your heart.”
Ans: D
Feedback:
Veins, unlike arteries, are equipped
with valves that allow blood to move against the force of gravity. The
legs have one-way bicuspid valves that prevent blood from seeping
backward as it moves forward by the muscles in our legs pressing on
the veins as we walk and increasing venous return. Leg arteries do
constrict when walking, which allows the blood to move faster and with
more pressure on the tissue, but the greater concern is increasing the
flow of venous blood to the heart. Walking increases, not decreases,
the heart’ pumping ability, which increases heart rate and blood
pressure and the hearts ability to manage stress. Walking does help
the heart adjust to new arteries and may enhance self-esteem, but the
patient had an MI—there are no “new arteries.”
16. The nurse is caring for a patient who is admitted to the medical
unit for the treatment of a venous ulcer in the area of her lateral
malleolus that has been unresponsive to treatment. What is the nurse
most likely to find during an assessment of this patient’s
wound?
A) Hemorrhage
B) Heavy exudate
C) Deep wound
bed
D) Pale-colored wound bed
Ans: B
Feedback:
Venous ulcerations in the area of the
medial or lateral malleolus (gaiter area) are typically large,
superficial, and highly exudative. Venous hypertension causes
extravasation of blood, which discolors the area of the wound bed.
Bleeding is not normally present.
17. The nurse is preparing to administer warfarin (Coumadin) to a
client with deep vein thrombophlebitis (DVT). Which laboratory value
would most clearly indicate that the patient’s warfarin is at
therapeutic levels?
A) Partial thromboplastin time (PTT) within
normal reference range
B) Prothrombin time (PT) eight to ten
times the control
C) International normalized ratio (INR) between
2 and 3
D) Hematocrit of 32%
Ans: C
Feedback:
The INR is most often used to determine
if 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.
18. The clinic nurse is caring for a 57-year-old client who reports
experiencing leg pain whenever she walks several blocks. The patient
has type 1 diabetes and has smoked a pack of cigarettes every day for
the past 40 years. The physician diagnoses intermittent claudication.
The nurse should provide what 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.”
Ans: A
Feedback:
The patient 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 patient should stop smoking—not just cut
down—because nicotine is a vasoconstrictor. Daily walking benefits the
patient with intermittent claudication. Increased protein intake will
not alleviate the patient’s symptoms.
19. A patient 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
patient for signs and symptoms of compartment syndrome every 2
hours.
D) Perform Doppler evaluation once daily.
Ans: A
Feedback:
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 patient’s status remains stable.
Doppler evaluations should be performed every 2 hours. Pain is
regularly assessed, but palpation is not the preferred method of
performing this assessment. Compartment syndrome results from the
placement of a cast, not from vascular surgery.
20. You are caring for a patient who is diagnosed with Raynaud’s
phenomenon. The nurse should plan interventions to address what
nursing diagnosis?
A) Chronic pain
B) Ineffective tissue
perfusion
C) Impaired skin integrity
D) Risk for injury
Ans: B
Feedback:
Raynaud’s 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
patient is not at a high risk for injury.
21. A patient presents to the clinic complaining of the inability to
grasp objects with her right hand. The patient’s right arm is cool and
has a difference in blood pressure of more than 20 mm Hg compared with
her left arm. The nurse should expect that the primary care provider
may diagnose the woman with what health problem?
A)
Lymphedema
B) Raynaud’s phenomenon
C) Upper extremity
arterial occlusive disease
D) Upper extremity VTE
Ans: C
Feedback:
The patient 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’s or
lymphedema. The upper extremities are rare sites for VTE.
22. 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 that she appears to
have early evidence of gangrene on one of her great toes. The nurse
knows that gangrene in the elderly is often the first sign of
what?
A) Chronic venous insufficiency
B) Raynaud’s
phenomenon
C) VTE
D) PAD
Ans: D
Feedback:
In elderly people, symptoms of PAD may
be more pronounced than in younger people. In elderly patients who are
inactive, gangrene may be the first sign of disease. Venous
insufficiency does not normally manifest with gangrene. Similarly, VTE
and Raynaud’s phenomenon do not cause the ischemia that underlies gangrene.
23. The prevention of VTE is an important part of the nursing care of
high-risk patients. When providing patient teaching for these
high-risk patients, the nurse should advise lifestyle changes,
including which of the following? Select all that apply.
A)
High-protein diet
B) Weight loss
C) Regular exercise
D)
Smoking cessation
E) Calcium and vitamin D supplementation
Ans: B, C, D
Feedback:
Patients at risk for VTE should be
advised to make lifestyle changes, as appropriate, which may include
weight loss, smoking cessation, and regular exercise. Increased
protein intake and supplementation with vitamin D and calcium do not
address the main risk factors for VTE.
24. The nurse is caring for an acutely ill patient who is on
anticoagulant therapy. The patient has a comorbidity of renal
insufficiency. How will this patient’s renal status affect heparin
therapy?
A) Heparin is contraindicated in the treatment of this
patient.
B) Heparin may be administered subcutaneously, but not
IV.
C) Lower doses of heparin are required for this
patient.
D) Coumadin will be substituted for heparin.
Ans: C
Feedback:
If renal insufficiency exists, lower
doses of heparin are required. Coumadin cannot be safely and
effectively used as a substitute and there is no contraindication for
IV administration.
25. The nurse is assessing a woman who is pregnant at 27 weeks’
gestation. The patient is concerned about the recent emergence of
varicose veins on the backs of her calves. What is the nurse’s best
response?
A) Facilitate a referral to a vascular surgeon.
B)
Assess the patient’s ankle-brachial index (ABI) and perform Doppler
ultrasound testing.
C) Encourage the patient to increase her
activity level.
D) Teach the patient that circulatory changes
during pregnancy frequently cause varicose veins.
Ans: D
Feedback:
Pregnancy may cause varicosities because
of hormonal effects related to decreased venous outflow, increased
pressure by the gravid uterus, and increased blood volume. In most
cases, no intervention or referral is necessary. This finding is not
an indication for ABI assessment and increased activity will not
likely resolve the problem.
26. Graduated compression stockings have been prescribed to treat a
patient’s venous insufficiency. What education should the nurse
prioritize when introducing this intervention to the patient?
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
Ans: D
Feedback:
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 patients, 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 patients
who are using compression stockings.
27. The nurse caring for a patient with a leg ulcer has finished
assessing the patient and is developing a problem list prior to
writing a plan of care. What major nursing diagnosis might the care
plan include?
A) Risk for disuse syndrome
B) Ineffective
health maintenance
C) Sedentary lifestyle
D) Imbalanced
nutrition: less than body requirements
Ans: D
Feedback:
Major nursing diagnoses for the patient
with leg ulcers may include imbalanced nutrition: less than body
requirements, related to increased need for nutrients that promote
wound healing. 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
sedentary lifestyle.
28. How should the nurse best position a patient who has leg ulcers
that are venous in origin?
A) Keep the patient’s legs flat and
straight.
B) Keep the patient’s knees bent to 45-degree angle and
supported with pillows.
C) Elevate the patient’s lower
extremities.
D) Dangle the patient’s legs over the side of the bed.
Ans: C
Feedback:
Positioning of the legs depends on
whether the ulcer is of arterial or venous origin. With venous
insufficiency, dependent edema can be avoided by elevating the lower
extremities. Dangling the patient’s legs and applying pillows may
further compromise venous return.
29. A patient with advanced venous insufficiency is confined
following orthopedic surgery. How can the nurse best prevent skin
breakdown in the patient’s lower extremities?
A) Ensure that the
patient’s heels are protected and supported.
B) Closely monitor
the patient’s serum albumin and prealbumin levels.
C) Perform
gentle massage of the patient’s lower legs, as tolerated.
D)
Perform passive range-of-motion exercises once per shift.
Ans: A
Feedback:
If the patient 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.
30. The nurse has performed a thorough nursing assessment of the care
of a patient with chronic leg ulcers. The nurse’s assessment should
include which of the following components? Select all that
apply.
A) Location and type of pain
B) Apical heart
rate
C) Bilateral comparison of peripheral pulses
D)
Comparison of temperature in the patient’s legs
E) Identification
of mobility limitations
Ans: A, C, D, E
Feedback:
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. Any limitation of mobility and activity
that results from vascular insufficiency is identified. Not likely is
there any direct indication for assessment of apical heart rate,
although peripheral pulses must be assessed.
31. A nurse on a medical unit is caring for a patient who has been
diagnosed with lymphangitis. When reviewing this patient’s medication
administration record, the nurse should anticipate which of the
following?
A) Coumadin (warfarin)
B) Lasix
(furosemide)
C) An antibiotic
D) An antiplatelet aggregator
Ans: C
Feedback:
Lymphangitis is an acute inflammation of
the lymphatic channels caused by an infectious process. Antibiotics
are always a component of treatment. Diuretics are of nominal use.
Anticoagulants and antiplatelet aggregators are not indicated in this
form of infection.
32. A postsurgical patient has illuminated her call light to inform
the nurse of a sudden onset of lower leg pain. On inspection, the
nurse observes that the patient’s left leg is visibly swollen and
reddened. What is the nurse’s most appropriate action?
A)
Administer a PRN dose of subcutaneous heparin.
B) Inform the
physician that the patient has signs and symptoms of VTE.
C)
Mobilize the patient promptly to dislodge any thrombi in the patient’s
lower leg.
D) Massage the patient’s lower leg to temporarily
restore venous return.
Ans: B
Feedback:
VTE requires prompt medical follow-up.
Heparin will not dissolve an established clot. Massaging the patient’s
leg and mobilizing the patient would be contraindicated because they
would dislodge the clot, possibly resulting in a pulmonary embolism.
33. A nurse is closely monitoring a patient who has recently been
diagnosed with an abdominal aortic aneurysm. What assessment finding
would signal an impending rupture of the patient’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
Ans: C
Feedback:
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.
34. A nurse is reviewing the physiological factors that affect a
patient’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
Ans: D
Feedback:
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 other answers do not apply.
35. The nurse is evaluating a patient’s diagnosis of arterial
insufficiency with reference to the adequacy of the patient’s blood
flow. On what physiological variables does adequate blood flow depend?
Select all that apply.
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
Ans: A, B, E
Feedback:
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.
Adequacy of blood flow does not primarily depend on the size of red
cells or their ratio to the number of platelets.
36. A nurse is assessing a new patient who is diagnosed with PAD. The
nurse cannot feel the pulse in the patient’s left foot. How should the
nurse proceed with assessment?
A) Have the primary care provider
order a CT.
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.
Ans: D
Feedback:
When pulses cannot be reliably palpated,
a hand-held continuous wave (CW) Doppler ultrasound device may be used
to hear (insonate) the blood flow in vessels. CT is not normally
warranted and the application of a tourniquet poses health risks and
will not aid assessment. Elevating the extremity would make palpation
more difficult.
37. A medical nurse has admitted four patients over the course of a
12-hour shift. For which patient would assessment of ankle-brachial
index (ABI) be most clearly warranted?
A) A patient who has
peripheral edema secondary to chronic heart failure
B) An older
adult patient who has a diagnosis of unstable angina
C) A patient
with poorly controlled type 1 diabetes who is a smoker
D) A
patient who has community-acquired pneumonia and a history of COPD
Ans: C
Feedback:
Nurses should perform a baseline ABI on
any patient with decreased pulses or any patient 50 years of age or
older with a history of diabetes or smoking. The other answers do not apply.
38. An older adult patient has been treated for a venous ulcer and a
plan is in place to prevent the occurrence of future ulcers. What
should the nurse include in this plan?
A) Use of supplementary
oxygen to aid tissue oxygenation
B) Daily use of normal saline
compresses on the lower limbs
C) Daily administration of
prophylactic antibiotics
D) A high-protein diet that is rich in vitamins
Ans: D
Feedback:
A diet that is high in protein, vitamins
C and A, iron, and zinc is encouraged to promote healing and prevent
future ulcers. Prophylactic antibiotics and saline compresses are not
used to prevent ulcers. Oxygen supplementation does not prevent ulcer formation.
39. A 79-year-old man is admitted to the medical unit with digital
gangrene. The man states that his problems first began when he stubbed
his toe going to the bathroom in the dark. In addition to this trauma,
the nurse should suspect that the patient has a history of what health
problem?
A) Raynaud’s phenomenon
B) CAD
C) Arterial
insufficiency
D) Varicose veins
Ans: C
Feedback:
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’s, CAD and
varicose veins are not the usual causes of digital gangrene in the elderly.
40. When assessing venous disease in a patient’s lower extremities,
the nurse knows that what test will most likely be ordered?
A)
Duplex ultrasonography
B) Echocardiography
C) Positron
emission tomography (PET)
D) Radiography
Ans: A
Feedback:
Duplex ultrasound may be used to
determine the level and extent of venous disease as well as its
chronicity. Radiographs (x-rays), PET scanning, and echocardiography
are never used for this purpose as they do not allow visualization of
blood flow.