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A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the pulse in the patients left foot. How should the nurse proceed with assessment?
- A. Have the primary care provider order a CT.
- B. Apply a tourniquet for 3 to 5 minutes and then reassess.
- C. Elevate the extremity and attempt to palpate the pulses.
- D. Use Doppler ultrasound to identify the pulses.
Correct Answer: D
Rationale: When pulses cannot be reliably palpated, a hand-held continuous wave (CW) Doppler ultrasound device may be used to hear (insonate) the blood flow in vessels. CT is not normally warranted and the application of a tourniquet poses health risks and will not aid assessment. Elevating the extremity would make palpation more difficult.
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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?
- A. Use of supplementary oxygen to aid tissue oxygenation
- B. Daily use of normal saline compresses on the lower limbs
- C. Daily administration of prophylactic antibiotics
- D. A high-protein diet that is rich in vitamins
Correct Answer: D
Rationale: A diet that is high in protein, vitamins C and A, iron, and zinc is encouraged to promote healing and prevent future ulcers. Prophylactic antibiotics and saline compresses are not used to prevent ulcers. Oxygen supplementation does not prevent ulcer formation.
How should the nurse best position a patient who has leg ulcers that are venous in origin?
- A. Keep the patients legs flat and straight.
- B. Keep the patients knees bent to 45-degree angle and supported with pillows.
- C. Elevate the patients lower extremities.
- D. Dangle the patients legs over the side of the bed.
Correct Answer: C
Rationale: Positioning of the legs depends on whether the ulcer is of arterial or venous origin. With venous insufficiency, dependent edema can be avoided by elevating the lower extremities. Dangling the patients legs and applying pillows may further compromise venous return.
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.
The nurse is reviewing the physiological factors that affect a patients cardiovascular health and tissue oxygenation. What is the systemic arteriovenous oxygen difference?
- A. The average amount of oxygen removed by each organ in the body
- B. The amount of oxygen removed from the blood by the heart
- C. The amount of oxygen returning to the lungs via the pulmonary artery
- D. The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood
Correct Answer: D
Rationale: The average amount of oxygen removed collectively by all of the body tissues is about 25%. This means that the blood in the vena cava contains about 25% less oxygen than aortic blood. This is known as the systemic arteriovenous oxygen difference. The other answers do not apply.
A 79-year-old man is admitted to the medical unit with digital gangrene. The man states that his problems first began when he 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 of what health problem?
- A. Raynauds phenomenon
- B. CAD
- C. Arterial insufficiency
- D. Varicose veins
Correct Answer: C
Rationale: Arterial insufficiency may result in gangrene of the toe (digital gangrene), which usually is caused by trauma. The toe is stubbed and then turns black. Raynauds, CAD and varicose veins are not the usual causes of digital gangrene in the elderly.