1.
A nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm. and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is:
Correct Answer
A. Normal because of the increased blood flow through the leg
Explanation
An expected outcome of surgery is warmth. redness. and edema in the surgical extremity because of increased blood flow.
2.
A client is admitted with a venous stasis leg ulcer. A nurse assesses the ulcer. expecting to note that the ulcer:
Correct Answer
D. Has brown pigmentation around it.
Explanation
Venous leg ulcers. also called stasis ulcers. tend to be more superficial than arterial ulcers. and the ulcer bed is pink. The edges of the ulcer are uneven. and granulation tissue is evident. The skin has a brown pigmentation from the accumulation of metabolic waste products resulting from venous stasis. The client also exhibits peripheral edema.Options A. B. and C is due to tissue malnutrition; and thus us an arterial problem)
3.
In preparation for the discharge of a client with arterial insufficiency and Raynaud’s disease. client teaching instructions should include:
Correct Answer
B. Keeping the heat up so that the environment is warm
Explanation
The client’s instructions should include keeping the environment warm to prevent vasoconstriction.Option A: Walking would most likely increase pain.Option C: Wearing gloves. warm clothes. and socks will also be useful when preventing vasoconstriction. but TED hose would not be therapeutic.
4.
A client comes to the outpatient clinic and tells the nurse that he has had legs pains that began when he walks but cease when he stops walking. Which of the following conditions would the nurse assess for?
Correct Answer
B. PeripHeral vascular problems in both legs
Explanation
Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system.Option A: If an obstruction were present. the leg pain would persist when the client stops walking.Option D: Low calcium levels may cause leg cramps but would not necessarily be related to walking.
5.
Which of the following characteristics is typical of the pain associated with DVT?
Correct Answer
C. Sudden onset
Explanation
DVT is associated with deep leg pain of sudden onset. which occurs secondary to the occlusion.Option A: A dull ache is more commonly associated with varicose veins.Option C: If the thrombus is large enough. it will cause pain.Option D: A tingling sensation is associated with an alteration in arterial blood flow.
6.
Cancer can cause changes in what component of Virchow’s triad?
Correct Answer
A. Blood coagulability
Explanation
Cancer can cause changes in blood coagulability, leading to an increased risk of blood clot formation. Tumors can release substances that activate the coagulation system, resulting in a hypercoagulable state. This can lead to the formation of blood clots in the blood vessels, which can obstruct blood flow and cause serious complications such as deep vein thrombosis or pulmonary embolism. Therefore, cancer can affect the blood's ability to coagulate properly, making blood coagulability an important component of Virchow's triad in the context of cancer.
7.
Varicose veins can cause changes in what component of Virchow’s triad?
Correct Answer
C. Blood flow
Explanation
Varicose veins occur when the valves in the veins become weak or damaged, causing blood to flow backward and pool in the veins. This pooling of blood disrupts the normal flow of blood, leading to changes in the blood flow component of Virchow's triad. Virchow's triad refers to the three factors that contribute to the formation of blood clots, which include changes in blood flow, vessel walls, and blood coagulability. In the case of varicose veins, the abnormal blood flow can increase the risk of blood clots forming in the affected veins.
8.
Which technique is considered the gold standard for diagnosing DVT?
Correct Answer
B. VenograpHy
Explanation
Venography is considered the gold standard for diagnosing DVT. Venography involves injecting a contrast dye into the veins and then taking X-ray images to visualize the blood flow and detect any blockages or clots. This technique provides a detailed and accurate assessment of the veins and is especially useful in identifying small or deep clots. Ultrasound imaging, MRI, and Doppler flow study are also commonly used for diagnosing DVT, but they may have limitations in certain cases compared to venography.
9.
A nurse is assessing a client with an abdominal aortic aneurysm. Which of the following assessment findings by the nurse is probably unrelated to an aneurysm?
Correct Answer
B. Hyperactive bowel sounds in that area
Explanation
Not all clients with abdominal aortic aneurysms exhibit symptoms.Option A: A pulsatile mass may be palpated in the middle and upper abdomen.Option C: A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm.Option D: Those who do describe a feeling of the “heart beating” in the abdomen when supine or be able to feel the mass throbbing.
10.
A nurse is caring for a client who had a percutaneous insertion of an inferior vena cava filter and was on heparin therapy before surgery. The nurse would inspect the surgical site most closely for signs of:
Correct Answer
B. Bleeding and infection
Explanation
After inferior vena cava insertion. the nurse inspects the surgical site for bleeding and signs and symptoms of infection. Otherwise. care is the same as for any post-op client.