English 1.1

1. Which health teaching will the nurse include in the continuing plan of care for a client with chronic venous stasis ulcers?

“Apply antiembolism stockings before getting out of bed in the morning.”

“Clean the ulcer with Betadine before applying a dressing.”

“Take one low-dose aspirin daily to prevent inflammation.”

“Remove and reapply the DuoDerm dressing daily.”

Support hose or antiembolism stockings should be applied just before getting out of bed in the morning and removed before going to bed at night. Clients also are advised that they will probably need to wear these stockings indefinitely. Betadine is not indicated and may cause irritation. Chronic venous ulcers are not caused by an inflammatory process, so daily aspirin is not indicated. Hydrocolloid (DuoDerm) dressings are left in place for a minimum of 3 to 5 days for best effect.

Explanation

Support hose or antiembolism stockings should be applied just before getting out of bed in the morning and removed before going to bed at night. Clients also are advised that they will probably need to wear these stockings indefinitely. Betadine is not indicated and may cause irritation. Chronic venous ulcers are not caused by an inflammatory process, so daily aspirin is not indicated. Hydrocolloid (DuoDerm) dressings are left in place for a minimum of 3 to 5 days for best effect.

2. A nurse is caring for a client who has undergone surgical repair of an AAA. The client has developed coolness of the extremities and complains of a bloated feeling in the abdomen. What is the nurse's best action?

Measuring the abdominal girth and check pulses

Raising the head of the bed to 90 degrees

Measuring the cardiac output

Irrigating the Foley catheter

Graft occlusion or rupture is a postoperative complication following AAA repair. The nurse should monitor the client for increasing abdominal girth, cool or cold extremities, white or blue color in the flanks, and severe pain. Elevating the head of the bed would place too much pressure on the surgical site.

Explanation

Graft occlusion or rupture is a postoperative complication following AAA repair. The nurse should monitor the client for increasing abdominal girth, cool or cold extremities, white or blue color in the flanks, and severe pain. Elevating the head of the bed would place too much pressure on the surgical site.

3. Which instructions would be most appropriate to include in a teaching plan for a client ready to be discharged after the repair of an AAA?

“You may drive your car any time.”

“Avoid sleeping on your left side.”

“Avoid lifting heavy objects for about 3 months.”

“You can expect to have an increase in abdominal girth for about 6 weeks.”

Clients who have undergone AAA repair must refrain from placing stress on the graft. They should avoid lifting or pulling heavy objects and activities such as vacuuming, raking leaves, and playing golf.

Explanation

Clients who have undergone AAA repair must refrain from placing stress on the graft. They should avoid lifting or pulling heavy objects and activities such as vacuuming, raking leaves, and playing golf.

4. Which intervention suggested to the client with Raynaud's disease is aimed at preventing complications?

“Take oral vasoconstrictive agents when you have symptoms.”

“Wear warm clothing when exposed to cool temperatures.”

“Avoid placing lotion on affected extremities.”

“Check the pulses in your arms and legs daily.”

Education is important for helping the client avoid complications. The client is instructed to wear warm clothing, such as socks and gloves, when exposed to cool temperatures to decrease vasoconstriction. The client may be prescribed vasodilators to prevent vasoconstriction.

Explanation

Education is important for helping the client avoid complications. The client is instructed to wear warm clothing, such as socks and gloves, when exposed to cool temperatures to decrease vasoconstriction. The client may be prescribed vasodilators to prevent vasoconstriction.

5. A client who has returned to the unit after arterial revascularization states that pain similar to that before the procedure is felt in the affected limb. Which is the nurse's best action?

Notifying the surgeon

Elevating the extremity

Administering pain medication

Placing a warm blanket on the operative limb

The surgeon should be notified if the client has an increase in ischemic pain because this signals graft occlusion. This is a surgical emergency and the nurse must recognize this as a sign of graft occlusion. Elevating the extremity would further compromise blood flow. Covering the extremity or administering pain addresses only the clinical manifestations, not the cause, of the compromised blood flow.

Explanation

The surgeon should be notified if the client has an increase in ischemic pain because this signals graft occlusion. This is a surgical emergency and the nurse must recognize this as a sign of graft occlusion. Elevating the extremity would further compromise blood flow. Covering the extremity or administering pain addresses only the clinical manifestations, not the cause, of the compromised blood flow.

6. Which instructions would be most appropriate to include in a teaching plan for a client ready to be discharged after the repair of an AAA?

Keeping environmental temperatures comfortably warm

Avoiding injury to the hands or feet

Using a heating pad on the feet

Smoking cessation

The greatest risk factor for the development and progression of Buerger’s disease is cigarette smoking. To prevent the progression of Buerger’s disease, complete abstinence from tobacco in all forms is essential. The vasoconstrictive effects of each cigarette may last up to 1 hour after the cigarette is smoked. Teach the client to avoid extreme cold or prolonged exposure to cold to prevent vasoconstriction. Keeping the environment warm will minimize vasoconstriction, but has no direct effect on disease progression. Heating pads should be avoided because injury can occur secondary to decreased sensation in the lower extremities.

Explanation

The greatest risk factor for the development and progression of Buerger’s disease is cigarette smoking. To prevent the progression of Buerger’s disease, complete abstinence from tobacco in all forms is essential. The vasoconstrictive effects of each cigarette may last up to 1 hour after the cigarette is smoked. Teach the client to avoid extreme cold or prolonged exposure to cold to prevent vasoconstriction. Keeping the environment warm will minimize vasoconstriction, but has no direct effect on disease progression. Heating pads should be avoided because injury can occur secondary to decreased sensation in the lower extremities.

7. The health care provider has prescribed the client sodium warfarin (Coumadin) while he or she is still receiving intravenous heparin. Which is the nurse's best action?

Administer the medications as prescribed.

Turn off the heparin drip for 1 hour before administration of the warfarin.

Discontinue the heparin drip completely before warfarin administration.

Hold the dose of warfarin.

Although both heparin and warfarin are anticoagulants, they have different mechanisms of action and onsets of action. Because warfarin has such a slow onset, it must be started while the client is still receiving heparin. Once the warfarin is therapeutic, as evidenced by the international normalized ratio (INR), the client’s heparin can be safely discontinued. Effects of heparin will be cleared from the client’s bloodstream within a few hours.

Explanation

Although both heparin and warfarin are anticoagulants, they have different mechanisms of action and onsets of action. Because warfarin has such a slow onset, it must be started while the client is still receiving heparin. Once the warfarin is therapeutic, as evidenced by the international normalized ratio (INR), the client’s heparin can be safely discontinued. Effects of heparin will be cleared from the client’s bloodstream within a few hours.

8. What instructions will the nurse provide to a client at risk of VTE who is being discharged home with low–molecular-weight heparin?

“You must have your aPTT checked every 2 weeks.”

“Massage the injection site after the heparin is injected.”

“Notify your health care provider if your stools appear tarry.”

“You will have an IV catheter placed that you can use for intermittent injection of the heparin.”

As with any anticoagulation, low–molecular-weight heparin incurs a risk of bleeding. Clients should be taught to report the presence of tarry stools, bleeding gums, hematuria, ecchymosis, or petechiae to their health care provider. Low–molecular-weight heparin does not affect aPTT as does intravenous heparin. This type of heparin is administered subcutaneously to deliver a slow sustained response. Massaging the site would hasten absorption and decrease effects.

Explanation

As with any anticoagulation, low–molecular-weight heparin incurs a risk of bleeding. Clients should be taught to report the presence of tarry stools, bleeding gums, hematuria, ecchymosis, or petechiae to their health care provider. Low–molecular-weight heparin does not affect aPTT as does intravenous heparin. This type of heparin is administered subcutaneously to deliver a slow sustained response. Massaging the site would hasten absorption and decrease effects.

9. In monitoring the client recovering from aortofemoral bypass surgery, which clinical manifestations are consistent with compartment syndrome?

Elevated temperature and diaphoresis

Loss of sensation and pallor proximal to surgical site

Swelling, pain, and tension of affected limb

Increased pulse amplitude and warmth below surgical site

Compartment syndrome occurs when tissue pressure within a confined space becomes elevated and blood flow is restricted. This causes increased swelling, tenderness, and tension in the affected limb.

Explanation

Compartment syndrome occurs when tissue pressure within a confined space becomes elevated and blood flow is restricted. This causes increased swelling, tenderness, and tension in the affected limb.

10. Which monitoring technique being performed by a new graduate nurse should be questioned in the client with an unrepaired abdominal aortic aneurysm?

Measurement of abdominal girth

Observation of abdominal wall movement

Auscultation of any area of the abdomen

Palpation of the abdominal midline area

Palpation on or near an aneurysm may cause pain and potential rupture. Observation, auscultation, and measurement are appropriate assessments.

Explanation

Palpation on or near an aneurysm may cause pain and potential rupture. Observation, auscultation, and measurement are appropriate assessments.

11. In assessing for skin changes in an African-American client admitted with peripheral artery disease, the nurse monitors for which change?

Excess hair growth on the arms and legs

Pitting edema in the feet

Cyanosis of the nail beds

Loss of toe nails

Because only severe cyanosis is evident in the skin of dark-skinned clients, cyanosis can be detected by assessing their skin and nail beds for a dull lifeless color. The soles of the feet and toenails are less pigmented and can enable detection of cyanosis or duskiness in the lower extremities. There is loss of hair on the lower extremities with peripheral artery disease. Pitting edema is associated with venous disease. Toenail beds are cyanotic, but there is no associated loss of nails.

Explanation

Because only severe cyanosis is evident in the skin of dark-skinned clients, cyanosis can be detected by assessing their skin and nail beds for a dull lifeless color. The soles of the feet and toenails are less pigmented and can enable detection of cyanosis or duskiness in the lower extremities. There is loss of hair on the lower extremities with peripheral artery disease. Pitting edema is associated with venous disease. Toenail beds are cyanotic, but there is no associated loss of nails.

12. A client with a diagnosed abdominal aortic aneurysm (AAA) develops lower back pain radiating to the groin. Which is the nurse's interpretation of this information?

The aneurysm has become obstructed.

The aneurysm may be undergoing expansion.

The client is experiencing inflammation of the aneurysm.

The client is experiencing normal sensations associated with this condition.

When an aneurysm is expanding or preparing to rupture, the client may experience severe, sudden back or lower abdominal pain that can radiate to the groin, buttocks, or legs. The other explanations are not related to potential or actual rupture of the aneurysm.

Explanation

When an aneurysm is expanding or preparing to rupture, the client may experience severe, sudden back or lower abdominal pain that can radiate to the groin, buttocks, or legs. The other explanations are not related to potential or actual rupture of the aneurysm.

13. The client is receiving heparin therapy for a venous thromboembolism (VTE). Which activated partial thromboplastin time (aPTT) indicates that anticoagulation is adequate?

The client’s aPPT is half of the control value.

The client’s aPPT is the same as the control value.

The client’s aPPT is twice the control value.

The client’s aPPT is five times the control value.

Therapeutic aPPT values for clients receiving heparin should range from 1.5 to 2.5 times the control value.

Explanation

Therapeutic aPPT values for clients receiving heparin should range from 1.5 to 2.5 times the control value.

14. A client who is receiving unfractionated heparin is experiencing excessive bleeding. Which medication will the nurse administer?

Warfarin

Vitamin K

Enoxaparin

Protamine sulfate

Protamine sulfate is the antidote for heparin-induced bleeding. Vitamin K is the antidote for warfarin. Warfarin (Coumadin) would increase bleeding. Enoxaparin is another name for heparin.

Explanation

Protamine sulfate is the antidote for heparin-induced bleeding. Vitamin K is the antidote for warfarin. Warfarin (Coumadin) would increase bleeding. Enoxaparin is another name for heparin.

15. In assessing the client with an aortic aneurysm before surgery, a nurse notes that the client's systolic blood pressure has increased by 30 mm Hg compared with the reading 1 hour ago. What is the nurse's best first action?

Measuring abdominal girth

Auscultating the abdomen

Increasing the IV rate

Measuring blood pressure in both arms

A sudden increase in blood pressure or hypertension can cause enlargement or rupture of the aneurysm, which would be correlated with an increase in abdominal girth.

Explanation

A sudden increase in blood pressure or hypertension can cause enlargement or rupture of the aneurysm, which would be correlated with an increase in abdominal girth.

16. Which nursing action is indicated for the client who has developed compartment syndrome after aortoiliac bypass graft surgery for peripheral arterial disease?

Performing passive range-of-motion exercise on the affected limb to increase flexibility

Preparing the client for return to the operative suite for surgical correction

Medicating the client for pain and placing the client in a knee-chest position

Loosening the dressing and elevating the extremity to the level of the heart

When a client develops compartment syndrome, the nurse should remove or loosen the dressing and elevate the extremity to the level of the heart. In addition, the nurse must also notify the health care provider immediately.

Explanation

When a client develops compartment syndrome, the nurse should remove or loosen the dressing and elevate the extremity to the level of the heart. In addition, the nurse must also notify the health care provider immediately.

17. In assessing the extremities of the client with Buerger's disease, the nurse correlates which clinical manifestations with this disease process?

Reddened, with diminished distal pulses

Cold and pale, with proximal bounding pulses

Cyanotic, with hyporeflexive distal deep tendon reflexes

Brownish, with hyperreflexive distal deep tendon reflexes

Clients with Buerger’s disease manifest with reddened or cyanotic extremities in the dependent position and diminished distal pulses because of occlusions in the smaller vessels. The client also may have ulcerations or gangrene of the digits secondary to impaired circulation. The pulses are diminished, not bounding. Reflex activity is not usually affected by this disorder.

Explanation

Clients with Buerger’s disease manifest with reddened or cyanotic extremities in the dependent position and diminished distal pulses because of occlusions in the smaller vessels. The client also may have ulcerations or gangrene of the digits secondary to impaired circulation. The pulses are diminished, not bounding. Reflex activity is not usually affected by this disorder.

18. In reviewing a clients laboratory results, the nurse correlates elevations in which values as risk factors for atherosclerosis? (Select all that apply.)

Total cholesterol

High-density cholesterol

Triglycerides

Serum albumin

Low-density cholesterol

Homocysteine

Clients with atherosclerosis often have elevated lipids, including cholesterol and triglycerides. Elevated cholesterol levels must be validated by HDL and LDL measurements. Elevated low-density lipoprotein cholesterol (LDL-C, or “bad” cholesterol) levels indicate that a person is at increased risk for atherosclerosis. Triglyceride levels may also be elevated with atherosclerosis, and levels of 150 mg/dL or higher indicate hypertriglyceridemia.

Explanation

Clients with atherosclerosis often have elevated lipids, including cholesterol and triglycerides. Elevated cholesterol levels must be validated by HDL and LDL measurements. Elevated low-density lipoprotein cholesterol (LDL-C, or “bad” cholesterol) levels indicate that a person is at increased risk for atherosclerosis. Triglyceride levels may also be elevated with atherosclerosis, and levels of 150 mg/dL or higher indicate hypertriglyceridemia.

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