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A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation. What is the most appropriate intervention for this diagnosis?
- A. Elevate his legs and arms above his heart when resting.
- B. Encourage the patient to engage in a moderate amount of exercise.
- C. Encourage extended periods of sitting or standing.
- D. Discourage walking in order to limit pain.
Correct Answer: B
Rationale: The nursing diagnosis of altered peripheral tissue perfusion related to compromised circulation requires interventions that focus on improving circulation. Encouraging the patient to engage in a moderate amount of exercise serves to improve circulation. Elevating his legs and arms above his heart when resting would be passive and fails to promote circulation. Encouraging long periods of sitting or standing would further compromise circulation. The nurse should encourage, not discourage, walking to increase circulation and decrease pain.
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Graduated compression stockings have been prescribed to treat a patients venous insufficiency. What education should the nurse prioritize when introducing this intervention to the patient?
- A. The need to take anticoagulants concurrent with using compression stockings
- B. The need to wear the stockings on a one day on, one day off schedule
- C. The importance of wearing the stockings around the clock to ensure maximum benefit
- D. The importance of ensuring the stockings are applied evenly with no pressure points
Correct Answer: D
Rationale: Any type of stocking can inadvertently become a tourniquet if applied incorrectly (i.e., rolled tightly at the top). In such instances, the stockings produce rather than prevent stasis. For ambulatory patients, graduated compression stockings are removed at night and reapplied before the legs are lowered from the bed to the floor in the morning. They are used daily, not on alternating days. Anticoagulants are not always indicated in patients who are using compression stockings.
A nurse is closely monitoring a patient who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the patients aneurysm?
- A. Sudden increase in blood pressure and a decrease in heart rate
- B. Cessation of pulsating in an aneurysm that has previously been pulsating visibly
- C. Sudden onset of severe back or abdominal pain
- D. New onset of hemoptysis
Correct Answer: C
Rationale: Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Impending rupture is not typically signaled by increased blood pressure, bradycardia, cessation of pulsing, or hemoptysis.
A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the patients left leg is visibly swollen and reddened. What is the nurses most appropriate action?
- A. Administer a PRN dose of subcutaneous heparin.
- B. Inform the physician that the patient has signs and symptoms of VTE.
- C. Mobilize the patient promptly to dislodge any thrombi in the patients lower leg.
- D. Massage the patients lower leg to temporarily restore venous return.
Correct Answer: B
Rationale: VTE requires prompt medical follow-up. Heparin will not dissolve an established clot. Massaging the patients leg and mobilizing the patient would be contraindicated because they would dislodge the clot, possibly resulting in a pulmonary embolism.
An occupational health nurse is providing an educational event and has been asked by an administrative worker about the risk of varicose veins. What should the nurse suggest as a proactive preventative measure for varicose veins?
- A. Sit with crossed legs for a few minutes each hour to promote relaxation.
- B. Walk for several minutes every hour to promote circulation.
- C. Elevate the legs when tired.
- D. Wear snug-fitting ankle socks to decrease edema.
Correct Answer: B
Rationale: A proactive approach to preventing varicose veins would be to walk for several minutes every hour to promote circulation. Sitting with crossed legs may promote relaxation, but it is contraindicated for patients with, or at risk for, varicose veins. Elevating the legs only helps blood passively return to the heart and does not help maintain the competency of the valves in the veins. Wearing tight 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.
The nurse is caring for an acutely ill patient who is on anticoagulant therapy. The patient has a comorbidity of renal insufficiency. How will this patients renal status affect heparin therapy?
- A. Heparin is contraindicated in the treatment of this patient.
- B. Heparin may be administered subcutaneously, but not IV.
- C. Lower doses of heparin are required for this patient.
- D. Coumadin will be substituted for heparin.
Correct Answer: C
Rationale: If renal insufficiency exists, lower doses of heparin are required. Coumadin cannot be safely and effectively used as a substitute and there is no contraindication for IV administration.