Nokea
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
Correct Answer: C
Rationale: 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.
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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 residents 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. Raynauds phenomenon
- C. VTE
- D. PAD
Correct Answer: D
Rationale: 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 Raynauds phenomenon do not cause the ischemia that underlies gangrene.
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.
Correct Answer: C
Rationale: 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.
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.
Correct Answer: A
Rationale: 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.
The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers. The nurses assessment should include which of the following components?
- A. Location and type of pain
- B. Apical heart rate
- C. Bilateral comparison of peripheral pulses
- D. Comparison of temperature in the patients legs
- E. Identification of mobility limitations
Correct Answer: A,C,D,E
Rationale: 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.
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 patients 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%
Correct Answer: C
Rationale: 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 clients 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.