Nokea
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.
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The nurse is providing teaching to a patient with newly diagnosed Raynaud's phenomenon about how to manage the condition. Which of the following behaviours by the patient indicates that the teaching has been effective?
- A. The patient avoids the use of Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).
- B. The patient exercises indoors during the winter months.
- C. The patient places the hands in hot water when they turn pale.
- D. The patient takes pseudoephedrine for cold symptoms.
Correct Answer: B
Rationale: Patients should avoid temperature extremes by exercising indoors when it is cold. To avoid burn injuries, the patient should use warm, rather than hot, water to warm the hands. Pseudoephedrine, a vasoconstrictor, should be avoided. There is no reason to avoid taking Aspirin and NSAIDs with Raynaud's phenomenon.
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.
Which of the following patient statements indicates a need for further teaching about management of peripheral artery disease (PAD)?
- A. I will have to buy some loose clothing that does not bind across my legs or waist.
- B. I will use a heating pad on my feet at night to increase the circulation and warmth in my feet.
- C. I will walk to the point of pain, rest, and walk again until I develop pain for a half hour daily.
- D. I will change my position every hour and avoid long periods of sitting with my legs down.
Correct Answer: B
Rationale: Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. The other patient statements are correct and indicate that teaching has been successful.
The nurse is caring for a patient with chronic atrial fibrillation who develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. Which of the following actions should the nurse implement first?
- A. Elevate the left leg on a pillow.
- B. Apply an elastic wrap to the leg.
- C. Assist the patient in gently exercising the leg.
- D. Notify the health care provider.
Correct Answer: D
Rationale: The patient's history and clinical manifestations are consistent with acute arterial occlusion. Clinical manifestations of acute arterial ischemia include the 'six Ps': pain, pallor, paralysis, pulselessness, paresthesia, and poikilothermia (adaptation of the limb to the environmental temperature most often cool). Without immediate intervention, ischemia may progress quickly to tissue necrosis and gangrene within a few hours. If the nurse detects these signs, the nurse should immediately notify the health care provider. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the leg.
The nurse is assessing a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the left great toe. Which of the following findings should the nurse expect?
- A. A positive Homans' sign
- B. Swollen, dry, scaly ankles
- C. Prolonged capillary refill in all the toes
- D. A large amount of drainage from the ulcer
Correct Answer: C
Rationale: Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease.