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How should the nurse best position a patient who has leg ulcers that are venous in origin?
- A. Keep the patients legs flat and straight.
- B. Keep the patients knees bent to 45-degree angle and supported with pillows.
- C. Elevate the patients lower extremities.
- D. Dangle the patients legs over the side of the bed.
Correct Answer: C
Rationale: Positioning of the legs depends on whether the ulcer is of arterial or venous origin. With venous insufficiency, dependent edema can be avoided by elevating the lower extremities. Dangling the patients legs and applying pillows may further compromise venous return.
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A medical nurse has admitted four patients over the course of a 12-hour shift. For which patient would assessment of ankle-brachial index (ABI) be most clearly warranted?
- A. A patient who has peripheral edema secondary to chronic heart failure
- B. An older adult patient who has a diagnosis of unstable angina
- C. A patient with poorly controlled type 1 diabetes who is a smoker
- D. A patient who has community-acquired pneumonia and a history of COPD
Correct Answer: C
Rationale: Nurses should perform a baseline ABI on any patient with decreased pulses or any patient 50 years of age or older with a history of diabetes or smoking. The other answers do not apply.
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.
The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission assessment that the patient takes oral contraceptives. Consequently, the nurses postoperative plan of care should include what intervention?
- A. Early ambulation and leg exercises
- B. Cessation of the oral contraceptives until 3 weeks postoperative
- C. Doppler ultrasound of peripheral circulation twice daily
- D. Dependent positioning of the patients extremities when at rest
Correct Answer: A
Rationale: Oral contraceptive use increases blood coagulability; with bed rest, the patient may be at increased risk of developing deep vein thrombosis. Leg exercises and early ambulation are among the interventions that address this risk. Assessment of peripheral circulation is important, but Doppler ultrasound may not be necessary to obtain these data. Dependent positioning increases the risk of venous thromboembolism (VTE). Contraceptives are not normally discontinued to address the risk of VTE in the short term.
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.
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.