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A patient with advanced venous insufficiency is confined following orthopedic surgery. How can the nurse best prevent skin breakdown in the patients lower extremities?
- A. Ensure that the patients heels are protected and supported.
- B. Closely monitor the patients serum albumin and prealbumin levels.
- C. Perform gentle massage of the patients lower legs, as tolerated.
- D. Perform passive range-of-motion exercises once per shift.
Correct Answer: A
Rationale: If the patient is on bed rest, it is important to relieve pressure on the heels to prevent pressure ulcerations, since the heels are among the most vulnerable body regions. Monitoring blood work does not directly prevent skin breakdown, even though albumin is related to wound healing. Massage is not normally indicated and may exacerbate skin breakdown. Passive range-of-motion exercises do not directly reduce the risk of skin breakdown.
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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.
The nurse is assessing a woman who is pregnant at 27 weeks gestation. The patient is concerned about the recent emergence of varicose veins on the backs of her calves. What is the nurses best response?
- A. Facilitate a referral to a vascular surgeon.
- B. Assess the patients ankle-brachial index (ABI) and perform Doppler ultrasound testing.
- C. Encourage the patient to increase her activity level.
- D. Teach the patient that circulatory changes during pregnancy frequently cause varicose veins.
Correct Answer: D
Rationale: Pregnancy may cause varicosities because of hormonal effects related to decreased venous outflow, increased pressure by the gravid uterus, and increased blood volume. In most cases, no intervention or referral is necessary. This finding is not an indication for ABI assessment and increased activity will not likely resolve the problem.
The nurse is taking a health history of a new patient. The patient reports experiencing pain in his left lower leg and foot when walking. This pain is relieved with rest. The nurse notes that the left lower leg is slightly edematous and is hairless. When planning this patients subsequent care, the nurse should most likely address what health problem?
- A. Coronary artery disease (CAD)
- B. Intermittent claudication
- C. Arterial embolus
- D. Raynauds disease
Correct Answer: B
Rationale: A muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest is experienced by patients with peripheral arterial insufficiency. Referred to as intermittent claudication, this pain is caused by the inability of the arterial system to provide adequate blood flow to the tissues in the face of increased demands for nutrients and oxygen during exercise. The nurse would not suspect the patient has CAD, arterial embolus, or Raynauds disease; none of these health problems produce this cluster of signs and symptoms.
The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain whenever she walks several blocks. The patient has type 1 diabetes and has smoked a pack of cigarettes every day for the past 40 years. The physician diagnoses intermittent claudication. The nurse should provide what instruction about long-term care to the client?
- A. Be sure to practice meticulous foot care.
- B. Consider cutting down on your smoking.
- C. Reduce your activity level to accommodate your limitations.
- D. Try to make sure you eat enough protein.
Correct Answer: A
Rationale: The patient with peripheral vascular disease or diabetes should receive education or reinforcement about skin and foot care. Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing; therefore, meticulous foot care is essential. The patient should stop smokingnot just cut downbecause nicotine is a vasoconstrictor. Daily walking benefits the patient with intermittent claudication. Increased protein intake will not alleviate the patients symptoms.
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.