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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.
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The nurse is caring for a patient who is admitted to the medical unit for the treatment of a venous ulcer in the area of her lateral malleolus that has been unresponsive to treatment. What is the nurse most likely to find during an assessment of this patients wound?
- A. Hemorrhage
- B. Heavy exudate
- C. Deep wound bed
- D. Pale-colored wound bed
Correct Answer: B
Rationale: Venous ulcerations in the area of the medial or lateral malleolus (gaiter area) are typically large, superficial, and highly exudative. Venous hypertension causes extravasation of blood, which discolors the area of the wound bed. Bleeding is not normally present.
A patient presents to the clinic complaining of the inability to grasp objects with her right hand. The patients right arm is cool and has a difference in blood pressure of more than 20 mm Hg compared with her left arm. The nurse should expect that the primary care provider may diagnose the woman with what health problem?
- A. Lymphedema
- B. Raynauds phenomenon
- C. Upper extremity arterial occlusive disease
- D. Upper extremity VTE
Correct Answer: C
Rationale: The patient with upper extremity arterial occlusive disease typically complains of arm fatigue and pain with exercise (forearm claudication) and inability to hold or grasp objects (e.g., combing hair, placing objects on shelves above the head) and, occasionally, difficulty driving. Assessment findings include coolness and pallor of the affected extremity, decreased capillary refill, and a difference in arm blood pressures of more than 20 mm Hg. These symptoms are not closely associated with Raynauds or lymphedema. The upper extremities are rare sites for VTE.
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.
The prevention of VTE is an important part of the nursing care of high-risk patients. When providing patient teaching for these high-risk patients, the nurse should advise lifestyle changes, including which of the following?
- A. High-protein diet
- B. Weight loss
- C. Regular exercise
- D. Smoking cessation
- E. Calcium and vitamin D supplementation
Correct Answer: B,C,D
Rationale: Patients at risk for VTE should be advised to make lifestyle changes, as appropriate, which may include weight loss, smoking cessation, and regular exercise. Increased protein intake and supplementation with vitamin D and calcium do not address the main risk factors for VTE.