Nokea
A patient at the clinic says, 'I have always taken an evening walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though.' Which of the following actions should the nurse implement?
- A. Attempt to palpate the dorsalis pedis and posterior tibial pulses.
- B. Check for the presence of tortuous veins bilaterally on the legs.
- C. Ask about any skin colour changes that occur in response to cold.
- D. Assess for unilateral swelling, redness, and tenderness of either leg.
Correct Answer: A
Rationale: The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin colour that occur in response to cold are consistent with Raynaud's phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness point to venous thromboembolism (VTE).
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The nurse is planning expected outcomes for a patient with thromboangiitis obliterans (Buerger's disease). Which of the following outcomes has the highest priority for this patient?
- A. Cessation of smoking
- B. Control of serum lipid levels
- C. Maintenance of appropriate weight
- D. Demonstration of meticulous foot care
Correct Answer: A
Rationale: Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with Buerger's disease. Other therapies have limited success in treatment of this disease.
A patient with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The patient asks the nurse why two medications are necessary. Which of the following responses by the nurse is accurate?
- A. Administration of two anticoagulants reduces the risk for recurrent venous thrombosis.
- B. Enoxaparin will start to dissolve the clot, and warfarin will prevent any more clots from occurring.
- C. The enoxaparin will work immediately, but the warfarin takes several days to have an effect on coagulation.
- D. Because of the potential for a pulmonary embolism, it is important for you to have more than one anticoagulant.
Correct Answer: C
Rationale: Low-molecular-weight heparin (LMWH) such as enoxaparin has an immediate effect on coagulation and is used until warfarin reaches therapeutic levels, which takes several days.
Several hours after an open surgical repair of an abdominal aortic aneurysm, the patient develops a urinary output of 20 mL/hour for 2 hours. Which of the following prescriptions should the nurse anticipate?
- A. An additional antibiotic
- B. White blood cell (WBC) count
- C. Decrease in IV infusion rate
- D. Blood urea nitrogen (BUN) level
Correct Answer: D
Rationale: The decreased urine output suggests decreased renal perfusion, and monitoring of renal function is needed. There is no indication that infection is a concern, so antibiotic therapy and a WBC count are not needed. The IV rate may be increased because hypovolemia may be contributing to the patient's decreased urinary output.
Which of the following nursing actions should be included in the plan of care for a patient who has had endovascular repair of an abdominal aortic aneurysm?
- A. Record hourly chest tube drainage.
- B. Monitor fluid intake and urine output.
- C. Check the abdominal wound for redness or swelling.
- D. Teach the reason for a prolonged rehabilitation process.
Correct Answer: B
Rationale: Because renal artery occlusion can occur after endovascular repair, the nurse should monitor parameters of renal function such as intake and output. Chest tubes will not be needed for endovascular surgery, the recovery period will be short, and there will not be an abdominal wound.
A patient is admitted to the hospital with a diagnosis of chronic venous insufficiency. Which of the following patient statements is most consistent with this diagnosis?
- A. I can't get my shoes on at the end of the day.
- B. I can never seem to get my feet warm enough.
- C. I wake up during the night because my legs hurt.
- D. I have burning leg pains after I walk three blocks.
Correct Answer: A
Rationale: Because the edema associated with venous insufficiency increases when the patient has been standing, shoes will feel tighter at the end of the day. The other patient statements are characteristic of peripheral artery disease (PAD).