Question 1

The nurse has identified the collaborative problem of potential complication: pulmonary embolism for a patient with left-calf DVT. Which nursing action is appropriate to include in the plan of care?

Accepted Answer

Decreasing muscle activity of the leg will help prevent thrombus dislodgement. There is no need to administer oxygen unless the patient develops a pulmonary embolism. Compression gradient stockings are ordered after resolution of the DVT to prevent further DVT. Exercising the muscles in the legs may prevent a new DVT, but it may dislodge the current thrombus if the patient has a DVT.

Question 2

A patient with a DVT is started on IV heparin and oral warfarin (Coumadin). The patient asks the nurse why two medications are necessary. The nurse's best response to the patient is,

Accepted Answer

IV heparin is used because of the immediate effect on coagulation and discontinued once the international normalized ratio (INR) value indicates that the warfarin has reached a therapeutic level. Heparin is not a thrombolytic drug. The use of two anticoagulants is not related to the risk for pulmonary embolism, and two are not necessary to reduce the risk for another DVT.

Question 3

The nurse identifies the nursing diagnosis of ineffective peripheral perfusion related to decreased arterial blood flow for a patient with chronic PAD. In evaluating the patient outcomes following patient teaching, the nurse determines a need for further instruction when the patient says,

Accepted Answer

Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. The other patient statements are correct and indicate that teaching has been successful.

Question 4

When the nurse is caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, the information that is most significant when the nurse is assessing for the return of peristalsis is

Accepted Answer

The passing of flatus is the best indicator of returning bowel function. Because the patient usually has an NG tube in place, the absence of abdominal distention is not indicative of gastrointestinal (GI) function. The quality of NG tube drainage may indicate the presence of complications such as GI bleeding but does not provide useful information about GI function. Moderate abdominal tenderness is expected after abdominal surgery.

Question 5

The nurse identifies a nursing diagnosis of risk for altered peripheral tissue perfusion related to bypass graft thrombosis for a patient following an abdominal aneurysm repair. An appropriate intervention to prevent this problem in the immediate postoperative period is to

Accepted Answer

Administration of IV fluids to maintain BP within normal range will allow adequate blood flow to prevent thrombosis while preventing the risk of suture damage that can occur with high BP. Coagulation is not usually affected by temperature. The Trendelenburg position compromises respiratory status in postoperative patients. Passive ROM will not improve arterial blood flow through the graft.

Question 6

A 72-year-old patient is hospitalized for an aortic dissection of the abdominal aorta that stabilizes with treatment. The nurse develops a teaching plan for the patient's discharge that includes information about

Accepted Answer

Antihypertensive medications are prescribed to help control BP and prevent re-dissection, leaking, or rupture. Exercise will increase the BP and increase the risk for further dissection. NSAIDs decrease platelet function, and the patient should avoid use of this category of medications; in addition, the patient is taught to call the health care provider about any abdominal pain. The patient may experience some side effects of b-blockade but should discuss any change in dose or medication with the health care provider.

Question 7

Several hours following a surgical repair of an abdominal aortic aneurysm, the patient develops left flank pain and a urinary output of 20 ml/hr for 2 hours. The nurse notifies the health care provider and anticipates orders for a(n)

Accepted Answer

The pain and decreased urine output suggest a renal artery embolism, and monitoring of renal function is needed. The data are not consistent with the complications of infection, hypovolemia, or bleeding.

Question 8

A patient who has had a femoral-popliteal bypass graft to the right leg is being cared for on the surgical unit. Which action by an LPN/LVN caring for the patient requires the RN to intervene?

Accepted Answer

The patient should avoid sitting for long periods because of the increased stress on the suture line caused by leg edema and because of the risk for DVT. The other actions by the LPN/LVN are appropriate.

Question 9

A 36-year-old patient who has a history of thromboangiitis obliterans (Buerger's disease) is admitted to the hospital with a gangrenous lesion of the right small toe. When the nurse is planning expected outcomes for the patient, which outcome has the highest priority for this patient?

Accepted Answer

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

Question 10

A patient with a history of a 4-cm abdominal aortic aneurysm is admitted to the emergency department with severe back pain and bilateral flank ecchymoses. The vital signs are blood pressure (BP) 90/58, pulse 138, and respirations 34. The nurse plans interventions for the patient based on the expectation that treatment will include

Accepted Answer

The patient's history and clinical manifestations are consistent with rupture into the retroperitoneal space, and the patient will need immediate surgery to have a chance at survival. The other listed treatments will all be too time consuming.

Question 11

A patient admitted to the hospital with DVT has health care provider's orders for bed rest with the feet elevated. The best method for the nurse to use in elevating the patient's feet is to

Accepted Answer

The purpose of elevation of the feet is to enhance venous flow from the feet to the right atrium, which is best accomplished by placing two pillows under the feet and one under the thighs. Placing the patient in the Trendelenburg position will lower the head below heart level, which is not indicated for this patient. Placing pillows under the calf or elevating the bed at the knee may cause blood stasis at the calf level.

Question 12

The health care provider orders a continuous IV heparin infusion for a patient with swelling and pain of the upper leg caused by a DVT. While the patient is receiving the heparin infusion, the nurse should

Accepted Answer

IM injections are avoided in patients receiving anticoagulation. A PTT of 50 seconds is within the therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by DVT.

Question 13

After teaching a patient with newly diagnosed Raynaud's phenomenon about how to manage the condition, which behavior by the patient indicates that the teaching has been effective?

Accepted Answer

Patients should avoid temperature extremes by exercising indoors when it is cold. To avoid burn injuries, the patient should use warm, rather than hot, water to warm the hands. Pseudoephedrine is a vasoconstrictor and should be avoided. There is no reason to avoid taking aspirin and NSAIDs with Raynaud's phenomenon.

Question 14

A nursing action that is indicated for the collaborative problem of potential complication: cardiac dysrhythmia in a patient who has had a repair of a descending thoracic aortic aneurysm is to

Accepted Answer

Hypoxemia may precipitate dysrhythmias in patients after aneurysm repair. Neurologic assessments, turning the patient, and monitoring intake and output are also appropriate nursing actions after aneurysm repair but will not have an effect on dysrhythmias.

Question 15

After repair of an abdominal aortic aneurysm, the nurse notes that the patient does not have popliteal, posterior tibial, or dorsalis pedis pulses. The legs are cool and mottled. Which action is appropriate for the nurse to take first?

Accepted Answer

Many patients with aortic aneurysms also have peripheral arterial disease, so the nurse should check the preoperative assessment to determine whether pulses were present before surgery before notifying the health care providers about the absent pulses. Because the patient's symptoms suggest graft occlusion or multiple emboli and a possible need to return to surgery, it is not appropriate to wait 30 minutes before taking action. Elevating the legs will decrease blood flow.

Question 16

The nurse performing an assessment with a patient who has chronic peripheral arterial disease (PAD) of the legs would expect to find

Accepted Answer

Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease.

Question 17

A patient recovering on a general surgical unit from an aortic valve replacement 1 week ago develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. The nurse should notify the health care provider and

Accepted Answer

The patient's history and clinical manifestations are consistent with acute arterial occlusion, and resting the leg will decrease the oxygen demand of the tissues and minimize ischemic damage until circulation can be restored. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise with increase oxygen demand for the tissues of the leg.

Question 18

A 69-year old patient is admitted to the hospital for elective repair of an abdominal aortic aneurysm. The history includes hypertension for 25 years, hyperlipidemia for 15 years, and smoking for 50 years. The patient asks the nurse what caused the aneurysm. The nurse's best response includes the information that

Accepted Answer

The patient's gender, age, and risk factor history indicate that the aneurysm was likely caused by atherosclerosis rather than a congenital weakness or chronic infection. Although the patient's BP, elevated lipids, and smoking undoubtedly have contributed to the atherosclerotic process, it is not appropriate for the nurse to imply that the patient is to blame.

Question 19

During an assessment of a 63-year-old patient at the clinic, the patient says, "I have always taken an evening walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." The nurse should

Accepted Answer

The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud's phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness point to deep vein thrombosis (DVT).

Question 20

A patient has a 5-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining a nursing history from the patient, the nurse will ask the patient about

Accepted Answer

Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the esophagus. Abdominal tenderness or changes in bowel habits are consistent with an abdominal aneurysm. Dizziness or weakness may occur if there is blood loss from the aneurysm, but this aneurysm was discovered accidentally, not because the patient was symptomatic.

Quiz 38: Nursing Management: Vascular Disorders