Nokea
Graduated compression stockings have been prescribed to treat a patients venous insufficiency. What education should the nurse prioritize when introducing this intervention to the patient?
- A. The need to take anticoagulants concurrent with using compression stockings
- B. The need to wear the stockings on a one day on, one day off schedule
- C. The importance of wearing the stockings around the clock to ensure maximum benefit
- D. The importance of ensuring the stockings are applied evenly with no pressure points
Correct Answer: D
Rationale: Any type of stocking can inadvertently become a tourniquet if applied incorrectly (i.e., rolled tightly at the top). In such instances, the stockings produce rather than prevent stasis. For ambulatory patients, graduated compression stockings are removed at night and reapplied before the legs are lowered from the bed to the floor in the morning. They are used daily, not on alternating days. Anticoagulants are not always indicated in patients who are using compression stockings.
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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.
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.
While assessing a patient the nurse notes that the patients ankle-brachial index (ABI) of the right leg is 0.40 . How should the nurse best respond to this assessment finding?
- A. Assess the patients use of over-the-counter dietary supplements.
- B. Implement interventions relevant to arterial narrowing.
- C. Encourage the patient to increase intake of foods high in vitamin K.
- D. Adjust the patients activity level to accommodate decreased coronary output.
Correct Answer: B
Rationale: ABI is used to assess the degree of stenosis of peripheral arteries. An ABI of less than 1.0 indicates possible claudication of the peripheral arteries. It does not indicate inadequate coronary output. There is no direct indication for changes in vitamin K intake and OTC medications are not likely causative.
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.
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.