Chapter 30: Assessment and Management of Patients With Vascular Diso

ders and Problems of Peripheral Circulation

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B
The nurse is taking a health history of a new patient. The patient
reports experiencing pain in his left lower leg and foot when Feedback:
walking. This pain is relieved with rest. The nurse notes that the left A muscular, cramp-type pain in the extremities consistently repro-
lower leg is slightly edematous and is hairless. When planning this duced with the same degree of exercise or activity and relieved by
patients subsequent care, the nurse should most likely address rest is experienced by patients with peripheral arterial insufficien-
what health problem? cy. Referred to as intermittent claudication, this pain is caused by
A) Coronary artery disease (CAD) the inability of the arterial system to provide adequate blood flow
B) Intermittent claudication to the tissues in the face of increased demands for nutrients and
C) Arterial embolus oxygen during exercise. The nurse would not suspect the patient
D) Raynauds disease has CAD, arterial embolus, or Raynauds disease; none of these
health problems produce this cluster of signs and symptoms.
While assessing a patient the nurse notes that the patients an-
kle-brachial index (ABI) of the right leg is 0.40. How should the B
nurse best respond to this assessment finding?
A) Assess the patients use of over-the-counter dietary supple- Feedback:
ments. ABI is used to assess the degree of stenosis of peripheral arteries.
B) Implement interventions relevant to arterial narrowing. An ABI of less than 1.0 indicates possible claudication of the pe-
C) Encourage the patient to increase intake of foods high in ripheral arteries. It does not indicate inadequate coronary output.
vitamin K. There is no direct indication for changes in vitamin K intake and
D) Adjust the patients activity level to accommodate decreased OTC medications are not likely causative.
coronary output.
B
The nurse is providing care for a patient who has just been
diagnosed with peripheral arterial occlusive disease (PAD). What
Feedback:
assessment finding is most consistent with this diagnosis?
PAD assessment may manifest as unequal pulses between ex-
A) Numbness and tingling in the distal extremities
tremities, with the affected leg cooler and paler than the unaffected
B) Unequal peripheral pulses between extremities
leg. Intermittent claudication is far more common than sensations
C) Visible clubbing of the fingers and toes
of numbness and tingling. Clubbing and muscle atrophy are not
D) Reddened extremities with muscle atrophy
associated with PAD.
A
The nurse is admitting a 32-year-old woman to the presurgical
unit. The nurse learns during the admission assessment that Feedback:
the patient takes oral contraceptives. Consequently, the nurses Oral contraceptive use increases blood coagulability; with bed
postoperative plan of care should include what intervention? rest, the patient may be at increased risk of developing deep
A) Early ambulation and leg exercises vein thrombosis. Leg exercises and early ambulation are among
B) Cessation of the oral contraceptives until 3 weeks postopera- the interventions that address this risk. Assessment of peripheral
tive circulation is important, but Doppler ultrasound may not be nec-
C) Doppler ultrasound of peripheral circulation twice daily essary to obtain these data. Dependent positioning increases the
D) Dependent positioning of the patients extremities when at rest risk of venous thromboembolism (VTE). Contraceptives are not
normally discontinued to address the risk of VTE in the short term.
A

A nurse is creating an education plan for a patient with venous Feedback:

insufficiency. What measure should the nurse include in the plan? Measures taken to prevent complications include avoiding tight-fit-
A) Avoiding tight-fitting socks. ting socks and panty girdles; maintaining activities, such as walk-
B) Limit activity whenever possible. ing, sleeping with legs elevated, and using pressure stockings.
C) Sleep with legs in a dependent position. Not included in the teaching plan for venous insufficiency would
D) Avoid the use of pressure stockings. be reducing activity, sleeping with legs dependent, and avoiding
pressure stockings. Each of these actions exacerbates venous
insufficiency.

A
The nurse is caring for a patient with a large venous leg ulcer.
What intervention should the nurse implement to promote healing
Feedback:
and prevent infection?
Wound healing is highly dependent on adequate nutrition. The
A) Provide a high-calorie, high-protein diet.
diet should be sufficiently high in calories and protein. Antibiotic
B) Apply a clean occlusive dressing once daily and whenever
ointments are not normally used on the skin surrounding a leg
soiled.
ulcer and
C) Irrigate the wound with hydrogen peroxide once daily.
occlusive dressings can exacerbate impaired blood flow. Hydro-

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 Chapter 30: Assessment and Management of Patients With Vascular Diso
ders and Problems of Peripheral Circulation
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D) Apply an antibiotic ointment on the surrounding skin with each gen peroxide is not normally used because it can damage granu-
dressing change. lation tissue.
A
The nurse is caring for a patient who returned from the tropics a
few weeks ago and who sought care with signs and symptoms
Feedback:
of lymphedema. The nurses plan of care should prioritize what
Lymphedema, which is caused by accumulation of lymph in the
nursing diagnosis?
tissues, constitutes a significant risk for infection. The patients
A) Risk for infection related to lymphedema
body image is likely to be disturbed, and the nurse should address
B) Disturbed body image related to lymphedema
this, but infection is a more significant threat to the patients physi-
C) Ineffective health maintenance related to lymphedema
ological well-being. Lymphedema is unrelated to ineffective health
D) Risk for deficient fluid volume related to lymphedema
maintenance and deficient fluid volume is not a significant risk.
B

Feedback:
worker about the risk of varicose veins. What should the nurse A proactive approach to preventing varicose veins would be to
suggest as a proactive preventative measure for varicose veins? walk for several minutes every hour to promote circulation. Sitting
A) Sit with crossed legs for a few minutes each hour to promote with crossed legs may promote relaxation, but it is contraindicated
relaxation. for patients with, or at risk for, varicose veins. Elevating the legs
B) Walk for several minutes every hour to promote circulation. only helps blood passively return to the heart and does not help
C) Elevate the legs when tired. maintain the competency of the valves in the veins. Wearing tight
D) Wear snug-fitting ankle socks to decrease edema. 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.
D

Feedback:
A patient comes to the walk-in clinic with complaints of pain in his Lymphangitis is an acute inflammation of the lymphatic channels.
foot following stepping on a roofing nail 4 days ago. The patient It arises most commonly from a focus of infection in an extremity.
has a visible red streak running up his foot and ankle. What health Usually, the infectious organism is hemolytic streptococcus. The
problem should the nurse suspect? characteristic red streaks that extend up the arm or the leg from an
A) Cellulitis infected wound outline the course of the lymphatic vessels as they
B) Local inflammation drain. Cellulitis is caused by bacteria, which cause a generalized
C) Elephantiasis edema in the subcutaneous tissues surrounding the affected area.
D) Lymphangitis Local inflammation would not present with red streaks in the lym-
phatic 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.
C
The triage nurse in the ED is assessing a patient who has pre-
sented with complaint of pain and swelling in her right lower leg.
Feedback:
The patients pain became much worse last night and appeared
Cellulitis is the most common infectious cause of limb swelling.
along with fever, chills, and sweating. The patient states, I hit my
The signs and symptoms include acute onset of swelling, localized
leg on the car door 4 or 5 days ago and it has been sore ever
redness, and pain; it is frequently associated with systemic signs
since. The patient has a history of chronic venous insufficiency.
of fever, chills, and sweating. The patient may be able to identify
What intervention should the nurse anticipate for this patient?
a trauma that accounts for the source of infection. Thrombocy-
A) Platelet transfusion to treat thrombocytopenia
topenia is a loss or decrease in platelets and increases a patients
B) Warfarin to treat arterial insufficiency
risk of bleeding; this problem would not cause these symptoms.
C) Antibiotics to treat cellulitis
Arterial insufficiency would present with ongoing pain related to
D) Heparin IV to treat VTE
activity. This patient does not have signs and symptoms of VTE.
B

A nurse in a long-term care facility is caring for an 83-year-old Feedback:

woman who has a history of HF and peripheral arterial disease Although the exact cause of venous thrombosis remains unclear,
(PAD). At present the patient is unable to stand or ambulate. The three factors, known as Virchows triad, are believed to play a
nurse should implement measures to prevent what complication? significant role in its development: stasis of blood (venous stasis),
A) Aoritis vessel wall injury, and altered blood coagulation. In this womans
B) Deep vein thrombosis 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,
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 Chapter 30: Assessment and Management of Patients With Vascular Diso
ders and Problems of Peripheral Circulation
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or mobility issues. The greatest risk factors for thoracic aortic
aneurysm are atherosclerosis and hypertension; there is no direct
C) Thoracic aortic aneurysm
connection to HF, PAD, or mobility issues. Raynauds disease is
D) Raynauds disease
a disorder that involves spasms of blood vessels and, again, no
direct connection to HF, PAD, or mobility issues.
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
C
reveals that he smokes about two packs of cigarettes a day, has
a history of alcohol abuse, and does not exercise. What would be
Feedback:
the priority health education for this patient?
Tobacco is powerful vasoconstrictor; its use with PAD is highly
A) The lack of exercise, which is the main cause of PAD.
detrimental, and patients are strongly advised to stop using tobac-
B) The likelihood that heavy alcohol intake is a significant risk
co. Sedentary lifestyle is also a risk factor, but smoking is likely a
factor for PAD.
more significant risk factor that the nurse should address. Alcohol
C) Cigarettes contain nicotine, which is a powerful vasoconstrictor
use is less likely to cause PAD, although it carries numerous health
and may cause or aggravate PAD.
risks.
D) Alcohol suppresses the immune system, creates high glucose
levels, and may cause PAD.
B
A nurse has written a plan of care for a man diagnosed with
peripheral arterial insufficiency. One of the nursing diagnoses in Feedback:
the care plan is altered peripheral tissue perfusion related to com- The nursing diagnosis of altered peripheral tissue perfusion re-
promised circulation. What is the most appropriate intervention for lated to compromised circulation requires interventions that focus
this diagnosis? on improving circulation. Encouraging the patient to engage in
A) Elevate his legs and arms above his heart when resting. a moderate amount of exercise serves to improve circulation.
B) Encourage the patient to engage in a moderate amount of Elevating his legs and arms above his heart when resting would
exercise. be passive and fails to promote circulation. Encouraging long
C) Encourage extended periods of sitting or standing. periods of sitting or standing would further compromise circulation.
D) Discourage walking in order to limit pain. The nurse should encourage, not discourage, walking to increase
circulation and decrease pain.
B
The nurse is caring for a 72-year-old patient who is in cardiac re-
Feedback:
habilitation following heart surgery. The patient has been walking
Intermittent claudication presents as a muscular, cramp-type pain
on a regular basis for about a week and walks for 15 minutes 3
in the extremities consistently reproduced with the same degree
times a day. The patient states that he is having a cramp-like pain
of exercise or activity and relieved by rest. Patients with peripheral
in the legs every time he walks and that the pain gets better when
arterial insufficiency often complain of intermittent claudication
I rest. The patients care plan should address what problem?
due to a lack of oxygen to muscle tissue. Venous insufficiency
A) Decreased mobility related to VTE
presents as a disorder of venous blood reflux and does not present
B) Acute pain related to intermittent claudication
with cramp-type pain with exercise. Vasculitis is an inflammation of
C) Decreased mobility related to venous insufficiency
the blood vessels and presents with weakness, fever, and fatigue,
D) Acute pain related to vasculitis
but does not present with cramp-type pain with exercise. The pain
associated with VTE does not have this clinical presentation.
D
A nurse in the rehabilitation unit is caring for an older adult patient
who is in cardiac rehabilitation following an MI. The nurses plan
of care calls for the patient to walk for 10 minutes 3 times a day. Feedback:
The patient questions the relationship between walking and heart Veins, unlike arteries, are equipped with valves that allow blood to
function. How should the nurse best reply? move against the force of gravity. The legs have one-way bicuspid
A) The arteries in your legs constrict when you walk and allow the valves that prevent blood from seeping backward as it moves
blood to move faster and with more pressure on the tissue. forward by the muscles in our legs pressing on the veins as we
B) Walking increases your heart rate and blood pressure. There- walk and increasing venous return. Leg arteries do constrict when
fore your heart is under less stress. walking, which allows the blood to move faster and with more
C) Walking helps your heart adjust to your new arteries and helps pressure on the tissue, but the greater concern is increasing the
build your self-esteem. flow of venous blood to the heart. Walking increases, not de-
D) When you walk, the muscles in your legs contract and pump creases, the heart pumping ability, which increases heart rate and
the blood in your veins back toward your heart, which allows more blood pressure and the hearts ability to manage stress. Walking
blood to return to your heart. does help the heart adjust to new arteries and may enhance
self-esteem, but the patient had an MIthere are no new arteries.
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
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 Chapter 30: Assessment and Management of Patients With Vascular Diso
ders and Problems of Peripheral Circulation
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malleolus that has been unresponsive to treatment. What is the B
nurse most likely to find during an assessment of this patients
wound? Feedback:
A) Hemorrhage Venous ulcerations in the area of the medial or lateral malleolus
B) Heavy exudate (gaiter area) are typically large, superficial, and highly exudative.
C) Deep wound bed Venous hypertension causes extravasation of blood, which discol-
D) Pale-colored wound bed ors the area of the wound bed. Bleeding is not normally present.
C
The nurse is preparing to administer warfarin (Coumadin) to a
Feedback:
client with deep vein thrombophlebitis (DVT). Which laboratory
The INR is most often used to determine if warfarin is at a ther-
value would most clearly indicate that the patients warfarin is at
apeutic level; an INR of 2 to 3 is considered therapeutic. Warfarin
therapeutic levels?
is also considered to be at therapeutic levels when the clients
A) Partial thromboplastin time (PTT) within normal reference
PT is 1.5 to 2 times the control. Higher values indicate increased
range
risk of bleeding and hemorrhage, whereas lower values indi-
B) Prothrombin time (PT) eight to ten times the control
cate increased risk of blood clot formation. Heparin, not warfarin,
C) International normalized ratio (INR) between 2 and 3
prolongs PTT. Hematocrit does not provide information on the
D) Hematocrit of 32%
effectiveness of warfarin; however, a falling hematocrit in a client
taking warfarin may be a sign of hemorrhage.
A
The clinic nurse is caring for a 57-year-old client who reports
experiencing leg pain whenever she walks several blocks. The Feedback:
patient has type 1 diabetes and has smoked a pack of cigarettes The patient with peripheral vascular disease or diabetes should
every day for the past 40 years. The physician diagnoses intermit- receive education or reinforcement about skin and foot care. In-
tent claudication. The nurse should provide what instruction about termittent claudication and other chronic peripheral vascular dis-
long-term care to the client? eases reduce oxygenation to the feet, making them susceptible
A) Be sure to practice meticulous foot care. to injury and poor healing; therefore, meticulous foot care is es-
B) Consider cutting down on your smoking. sential. The patient should stop smokingnot just cut downbecause
C) Reduce your activity level to accommodate your limitations. nicotine is a vasoconstrictor. Daily walking benefits the patient with
D) Try to make sure you eat enough protein. intermittent claudication. Increased protein intake will not alleviate
the patients symptoms.
A

A patient who has undergone a femoral to popliteal bypass graft The primary objective in the postoperative period is to maintain
surgery returns to the surgical unit. Which assessments should adequate circulation through the arterial repair. Pulses, Doppler
the nurse perform during the first postoperative day? assessment, color and temperature, capillary refill, and sensory
A) Assess pulse of affected extremity every 15 minutes at first. and motor function of the affected extremity are checked and com-
B) Palpate the affected leg for pain during every assessment. pared with those of the other extremity; these values are recorded
C) Assess the patient for signs and symptoms of compartment initially every 15 minutes and then at progressively longer intervals
syndrome every 2 hours. if the patients status remains stable. Doppler evaluations should
D) Perform Doppler evaluation once daily. be performed every 2 hours. Pain is regularly assessed, but pal-
pation is not the preferred method of performing this assessment.
Compartment syndrome results from the placement of a cast, not
from vascular surgery.
B
You are caring for a patient who is diagnosed with Raynauds
phenomenon. The nurse should plan interventions to address
Feedback:
what nursing diagnosis?
Raynauds phenomenon is a form of intermittent arteriolar vaso-
A) Chronic pain
constriction resulting in inadequate tissue perfusion. This results in
B) Ineffective tissue perfusion
coldness, pain, and pallor of the fingertips or toes. Pain is typically
C) Impaired skin integrity
intermittent and acute, not chronic, and skin integrity is rarely at
D) Risk for injury
risk. In most cases, the patient is not at a high risk for injury.
C
A patient presents to the clinic complaining of the inability to grasp
objects with her right hand. The patients right arm is cool and has
Feedback:
a difference in blood pressure of more than 20 mm Hg compared
The patient with upper extremity arterial occlusive disease typ-
with her left arm. The nurse should expect that the primary care
ically complains of arm fatigue and pain with exercise (forearm
provider may diagnose the woman with what health problem?
claudication) and inability to hold or grasp objects (e.g., combing
A) Lymphedema
hair, placing objects on shelves above the head) and, occasion-
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 Chapter 30: Assessment and Management of Patients With Vascular Diso
ders and Problems of Peripheral Circulation
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ally, difficulty driving. Assessment findings include coolness and
B) Raynauds phenomenon pallor of the affected extremity, decreased capillary refill, and
C) Upper extremity arterial occlusive disease a difference in arm blood pressures of more than 20 mm Hg.
D) Upper extremity VTE These symptoms are not closely associated with Raynauds 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. D
During inspection of the residents feet, the nurse notes that she
appears to have early evidence of gangrene on one of her great Feedback:
toes. The nurse knows that gangrene in the elderly is often the In elderly people, symptoms of PAD may be more pronounced
first sign of what? than in younger people. In elderly patients who are inactive, gan-
A) Chronic venous insufficiency grene may be the first sign of disease. Venous insufficiency does
B) Raynauds phenomenon not normally manifest with gangrene. Similarly, VTE and Raynauds
C) VTE phenomenon do not cause the ischemia that underlies gangrene.
D) PAD
The prevention of VTE is an important part of the nursing care
B, C, D
of high-risk patients. When providing patient teaching for these
high-risk patients, the nurse should advise lifestyle changes, in-
Feedback:
cluding which of the following? Select all that apply.
Patients at risk for VTE should be advised to make lifestyle
A) High-protein diet
changes, as appropriate, which may include weight loss, smok-
B) Weight loss
ing cessation, and regular exercise. Increased protein intake and
C) Regular exercise
supplementation with vitamin D and calcium do not address the
D) Smoking cessation
main risk factors for VTE.
E) Calcium and vitamin D supplementation
The nurse is caring for an acutely ill patient who is on anticoag-
ulant therapy. The patient has a comorbidity of renal insufficiency. C
How will this patients renal status affect heparin therapy?
Feedback:
A) Heparin is contraindicated in the treatment of this patient. If renal insufficiency exists, lower doses of heparin are required.
B) Heparin may be administered subcutaneously, but not IV. Coumadin cannot be safely and effectively used as a substitute
C) Lower doses of heparin are required for this patient. and there is no contraindication for IV administration.
D) Coumadin will be substituted for heparin.
The nurse is assessing a woman who is pregnant at 27 weeks
D
gestation. The patient is concerned about the recent emergence
of varicose veins on the backs of her calves. What is the nurses
Feedback:
best response?
Pregnancy may cause varicosities because of hormonal effects
A) Facilitate a referral to a vascular surgeon.
related to decreased venous outflow, increased pressure by the
B) Assess the patients ankle-brachial index (ABI) and perform
gravid uterus, and increased blood volume. In most cases, no in-
Doppler ultrasound testing.
tervention or referral is necessary. This finding is not an indication
C) Encourage the patient to increase her activity level.
for ABI assessment and increased activity will not likely resolve
D) Teach the patient that circulatory changes during pregnancy
the problem.
frequently cause varicose veins.
Graduated compression stockings have been prescribed to treat D
a patients venous insufficiency. What education should the nurse
prioritize when introducing this intervention to the patient? Feedback:
A) The need to take anticoagulants concurrent with using com- Any type of stocking can inadvertently become a tourniquet if
pression stockings applied incorrectly (i.e., rolled tightly at the top). In such instances,
B) The need to wear the stockings on a one day on, one day off the stockings produce rather than prevent stasis. For ambulatory
schedule patients, graduated compression stockings are removed at night
C) The importance of wearing the stockings around the clock to and reapplied before the legs are lowered from the bed to the
ensure maximum benefit floor in the morning. They are used daily, not on alternating days.
D) The importance of ensuring the stockings are applied evenly Anticoagulants are not always indicated in patients who are using
with no pressure points compression stockings.
D
The nurse caring for a patient with a leg ulcer has finished assess-
ing the patient and is developing a problem list prior to writing a Feedback:
plan of care. What major nursing diagnosis might the care plan Major nursing diagnoses for the patient with leg ulcers may in-
include? clude imbalanced nutrition: less than body requirements, related
A) Risk for disuse syndrome to increased need for nutrients that promote wound healing. Risk
for disuse syndrome is a state in which an individual is at risk for
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 Chapter 30: Assessment and Management of Patients With Vascular Diso
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deterioration of body systems owing to prescribed or unavoidable
B) Ineffective health maintenance
musculoskeletal inactivity. A leg ulcer will affect activity, but rarely
C) Sedentary lifestyle
to this degree. Leg ulcers are not necessarily a consequence of
D) Imbalanced nutrition: less than body requirements
ineffective health maintenance or sedentary lifestyle.
C
How should the nurse best position a patient who has leg ulcers
that are venous in origin?
Feedback:
A) Keep the patients legs flat and straight.
Positioning of the legs depends on whether the ulcer is of arterial
B) Keep the patients knees bent to 45-degree angle and support-
or venous origin. With venous insufficiency, dependent edema
ed with pillows.
can be avoided by elevating the lower extremities. Dangling the
C) Elevate the patients lower extremities.
patients legs and applying pillows may further compromise venous
D) Dangle the patients legs over the side of the bed.
return.
A
A patient with advanced venous insufficiency is confined following
orthopedic surgery. How can the nurse best prevent skin break-
Feedback:
down in the patients lower extremities?
If the patient is on bed rest, it is important to relieve pressure on the
A) Ensure that the patients heels are protected and supported.
heels to prevent pressure ulcerations, since the heels are among
B) Closely monitor the patients serum albumin and prealbumin
the most vulnerable body regions. Monitoring blood work does not
levels.
directly prevent skin breakdown, even though albumin is related
C) Perform gentle massage of the patients lower legs, as tolerat-
to wound healing. Massage is not normally indicated and may
ed.
exacerbate skin breakdown. Passive range- of-motion exercises
D) Perform passive range-of-motion exercises once per shift.
do not directly reduce the risk of skin breakdown.
A, C, D, E
The nurse has performed a thorough nursing assessment of the
care of a patient with chronic leg ulcers. The nurses assessment Feedback:
should include which of the following components? Select all that A careful nursing history and assessment are important. The ex-
apply. tent and type of pain are carefully assessed, as are the appear-
A) Location and type of pain ance and temperature of the skin of both legs. The quality of all
B) Apical heart rate peripheral pulses is assessed, and the pulses in both legs are
C) Bilateral comparison of peripheral pulses compared. Any limitation of mobility and activity that results from
D) Comparison of temperature in the patients legs vascular insufficiency is identified. Not likely is there any direct
E) Identification of mobility limitations indication for assessment of apical heart rate, although peripheral
pulses must be assessed.
A nurse on a medical unit is caring for a patient who has been C
diagnosed with lymphangitis. When reviewing this patients med-
ication administration record, the nurse should anticipate which of
the following? Feedback:
A) Coumadin (warfarin) Lymphangitis is an acute inflammation of the lymphatic channels
B) Lasix (furosemide) caused by an infectious process. Antibiotics are always a compo-
C) An antibiotic nent of treatment. Diuretics are of nominal use. Anticoagulants and
D) An antiplatelet aggregator antiplatelet aggregators are not indicated in this form of infection.
A postsurgical patient has illuminated her call light to inform the
nurse of a sudden onset of lower leg pain. On inspection, the nurse
B
observes that the patients left leg is visibly swollen and reddened.
What is the nurses most appropriate action?
Feedback:
A) Administer a PRN dose of subcutaneous heparin.
VTE requires prompt medical follow-up. Heparin will not dissolve
B) Inform the physician that the patient has signs and symptoms
an established clot. Massaging the patients leg and mobilizing the
of VTE.
patient would be contraindicated because they would dislodge the
C) Mobilize the patient promptly to dislodge any thrombi in the pa-
clot, possibly resulting in a pulmonary embolism.
tients lower leg. D) Massage the patients lower leg to temporarily
restore venous return.

A nurse is closely monitoring a patient who has recently been

C
diagnosed with an abdominal aortic aneurysm. What assess-
ment finding would signal an impending rupture of the patients
Feedback:
aneurysm?
Signs of impending rupture include severe back or abdominal
A) Sudden increase in blood pressure and a decrease in heart
pain, which may be persistent or intermittent. Impending rupture
rate
is not typically signaled by increased blood pressure, bradycardia,
B) Cessation of pulsating in an aneurysm that has previously been
cessation of pulsing, or hemoptysis.
pulsating visibly

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 Chapter 30: Assessment and Management of Patients With Vascular Diso
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C) Sudden onset of severe back or abdominal pain
D) New onset of hemoptysis
A nurse is reviewing the physiological factors that affect a patients
cardiovascular health and tissue oxygenation. What is the sys- D
temic arteriovenous oxygen difference?
A) The average amount of oxygen removed by each organ in the Feedback:
body The average amount of oxygen removed collectively by all of the
B) The amount of oxygen removed from the blood by the heart body tissues is about 25%. This means that the blood in the vena
C) The amount of oxygen returning to the lungs via the pulmonary cava contains about 25% less oxygen than aortic blood. This is
artery known as the systemic arteriovenous oxygen difference. The other
D) The amount of oxygen in aortic blood minus the amount of answers do not apply.
oxygen in the vena caval blood
The nurse is evaluating a patients diagnosis of arterial insufficien-
A, B, E
cy with reference to the adequacy of the patients blood flow. On
what physiological variables does adequate blood flow depend?
Feedback:
Select all that apply.
Adequate blood flow depends on the efficiency of the heart as a
A) Efficiency of heart as a pump
pump, the patency and responsiveness of the blood vessels, and
B) Adequacy of circulating blood volume
the adequacy of circulating blood volume. Adequacy of blood flow
C) Ratio of platelets to red blood cells
does not primarily depend on the size of red cells or their ratio to
D) Size of red blood cells
the number of platelets.
E) Patency and responsiveness of the blood vessels
D
A nurse is assessing a new patient who is diagnosed with PAD.
The nurse cannot feel the pulse in the patients left foot. How
Feedback:
should the nurse proceed with assessment?
When pulses cannot be reliably palpated, a hand-held continuous
A) Have the primary care provider order a CT.
wave (CW) Doppler ultrasound device may be used to hear (in-
B) Apply a tourniquet for 3 to 5 minutes and then reassess.
sonate) the blood flow in vessels. CT is not normally warranted and
C) Elevate the extremity and attempt to palpate the pulses.
the application of a tourniquet poses health risks and will not aid
D) Use Doppler ultrasound to identify the pulses.
assessment. Elevating the extremity would make palpation more
difficult.
A medical nurse has admitted four patients over the course
of a 12-hour shift. For which patient would assessment of an-
C
kle-brachial index (ABI) be most clearly warranted?
A) A patient who has peripheral edema secondary to chronic heart
Feedback:
failure
Nurses should perform a baseline ABI on any patient with de-
B) An older adult patient who has a diagnosis of unstable angina
creased pulses or any patient 50 years of age or older with a
C) A patient with poorly controlled type 1 diabetes who is a smoker
history of diabetes or smoking. The other answers do not apply.
D) A patient who has community-acquired pneumonia and a
history of COPD
D
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?
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A) Use of supplementary oxygen to aid tissue oxygenation
A diet that is high in protein, vitamins C and A, iron, and zinc is
B) Daily use of normal saline compresses on the lower limbs
encouraged to promote healing and prevent future ulcers. Prophy-
C) Daily administration of prophylactic antibiotics
lactic antibiotics and saline compresses are not used to prevent
D) A high-protein diet that is rich in vitamins
ulcers. Oxygen supplementation does not prevent ulcer formation.
A 79-year-old man is admitted to the medical unit with digital
gangrene. The man states that his problems first began when he C
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 Feedback:
of what health problem? Arterial insufficiency may result in gangrene of the toe (digital
A) Raynauds phenomenon gangrene), which usually is caused by trauma. The toe is stubbed
B) CAD and then turns black. Raynauds, CAD and varicose veins are not
C) Arterial insufficiency the usual causes of digital gangrene in the elderly.
D) Varicose veins
When assessing venous disease in a patients lower extremities, A
the nurse knows that what test will most likely be ordered?
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Chapter 30: Assessment and Management of Patients With Vascular Diso
ders and Problems of Peripheral Circulation
Study online at https://quizlet.com/_6jm6q0
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A) Duplex ultrasonography
Duplex ultrasound may be used to determine the level and extent
B) Echocardiography
of venous disease as well as its chronicity. Radiographs (x-rays),
C) Positron emission tomography (PET)
PET scanning, and echocardiography are never used for this
D) Radiography
purpose as they do not allow visualization of blood flow.

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