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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.
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The nurse is discussing risk factor modification for a patient who has a 4-cm abdominal aortic aneurysm. The nurse should focus patient teaching on which of the following risk factors?
- A. Male gender
- B. Marfan syndrome
- C. Abdominal trauma history
- D. Uncontrolled hypertension
Correct Answer: D
Rationale: All of the factors contribute to the patient's risk, but only the hypertension can potentially be modified to decrease the patient's risk for further expansion of the aneurysm.
The nurse is assessing a patient in the emergency department with a history of an abdominal aortic aneurysm with severe back pain and absent pedal pulses. Which of the following actions should the nurse take first?
- A. Obtain the blood pressure.
- B. Ask the patient about tobacco use.
- C. Draw blood for ordered laboratory testing.
- D. Assess for the presence of an abdominal bruit.
Correct Answer: A
Rationale: Since the patient appears to be experiencing aortic dissection, the nurse's first action should be to determine the hemodynamic status by assessing blood pressure. The other actions also may be done, but they will not provide information that will determine what interventions are needed immediately for this patient.
The nurse is assessing a patient with possible peripheral artery disease (PAD) and obtains a brachial BP of 140/80 and an ankle pressure of 110/70. The nurse calculates the patient's ankle-brachial index (ABI) as
Correct Answer: 0.78 or 0.79
Rationale: The ABI is calculated by dividing the ankle systolic BP by the brachial systolic BP (110/140 â?? 0.78 or 0.79).
Which of the following patients in the emergency department should the nurse assess first?
- A. 62-year-old who has gangrenous ulcers on both feet
- B. 50-year-old who is complaining of 'tearing' chest pain.
- C. 45-year-old who is taking anticoagulants and has bloody stools
- D. 36-year-old who has right calf tenderness, redness, and swelling
Correct Answer: B
Rationale: The patient's presentation is consistent with aortic dissection, which will require rapid intervention. The other patients do not need urgent interventions.
The health care provider prescribes an infusion of argatroban and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). Which of the following actions should the nurse include in the plan of care?
- A. Avoid giving any IM medications to prevent localized bleeding.
- B. Discontinue the infusion for PTT values greater than 50 seconds.
- C. Monitor posterior tibial and dorsalis pedis pulses with the Doppler.
- D. Have vitamin K available in case reversal of the argatroban is needed.
Correct Answer: A
Rationale: IM injections are avoided in patients receiving anticoagulation. A PTT of 50 seconds is within the therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by VTE.