Nokea
A nurse on a medical unit is caring for a patient who has been diagnosed with lymphangitis. When reviewing this patients medication administration record, the nurse should anticipate which of the following?
- A. Coumadin (warfarin)
- B. Lasix (furosemide)
- C. An antibiotic
- D. An antiplatelet aggregator
Correct Answer: C
Rationale: Lymphangitis is an acute inflammation of the lymphatic channels caused by an infectious process. Antibiotics are always a component of treatment. Diuretics are of nominal use. Anticoagulants and antiplatelet aggregators are not indicated in this form of infection.
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The nurse is caring for a patient who returned from the tropics a few weeks ago and who sought care with signs and symptoms of lymphedema. The nurses plan of care should prioritize what nursing diagnosis?
- A. Risk for infection related to lymphedema
- B. Disturbed body image related to lymphedema
- C. Ineffective health maintenance related to lymphedema
- D. Risk for deficient fluid volume related to lymphedema
Correct Answer: A
Rationale: Lymphedema, which is caused by accumulation of lymph in the tissues, constitutes a significant risk for infection. The patients body image is likely to be disturbed, and the nurse should address this, but infection is a more significant threat to the patients physiological well-being. Lymphedema is unrelated to ineffective health maintenance and deficient fluid volume is not a significant risk.
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 evaluating a patients diagnosis of arterial insufficiency with reference to the adequacy of the patients blood flow. On what physiological variables does adequate blood flow depend?
- A. Efficiency of heart as a pump
- B. Adequacy of circulating blood volume
- C. Ratio of platelets to red blood cells
- D. Size of red blood cells
- E. Patency and responsiveness of the blood vessels
Correct Answer: A,B,E
Rationale: Adequate blood flow depends on the efficiency of the heart as a pump, the patency and responsiveness of the blood vessels, and the adequacy of circulating blood volume. Adequacy of blood flow does not primarily depend on the size of red cells or their ratio to the number of platelets.
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.
The nurse is caring for a 72-year-old patient who is in cardiac rehabilitation following heart surgery. The patient has been walking on a regular basis for about a week and walks for 15 minutes 3 times a day. The patient states that he is having a cramp-like pain in the legs every time he walks and that the pain gets better when I rest. The patients care plan should address what problem?
- A. Decreased mobility related to VTE
- B. Acute pain related to intermittent claudication
- C. Decreased mobility related to venous insufficiency
- D. Acute pain related to vasculitis
Correct Answer: B
Rationale: Intermittent claudication presents as a muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest. Patients with peripheral arterial insufficiency often complain of intermittent claudication due to a lack of oxygen to muscle tissue. Venous insufficiency presents as a disorder of venous blood reflux and does not present with cramp-type pain with exercise. Vasculitis is an inflammation of the blood vessels and presents with weakness, fever, and fatigue, but does not present with cramp-type pain with exercise. The pain associated with VTE does not have this clinical presentation.