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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).
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A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which of the following medication categories should the nurse plan to include when providing patient teaching about PAD management?
- A. Statins
- B. Vitamins
- C. Thrombolytics
- D. Anticoagulants
Correct Answer: A
Rationale: Current research indicates that statin use by patients with PAD improves multiple outcomes. There is no research that supports the use of the other medication categories in PAD.
The nurse is caring for a patient with a right calf venous thromboembolism. Which of the following information requires immediate action by the nurse?
- A. Complaint of left calf pain
- B. New onset shortness of breath
- C. Red skin colour of left lower leg
- D. Temperature of 38°C (100.4°F)
Correct Answer: B
Rationale: New onset dyspnea suggests a pulmonary embolus, which will require rapid actions such as oxygen administration and notification of the health care provider. The other findings are typical of VTE.
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.
A patient at the clinic says, 'I have always taken an evening walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though.' Which of the following actions should the nurse implement?
- A. Attempt to palpate the dorsalis pedis and posterior tibial pulses.
- B. Check for the presence of tortuous veins bilaterally on the legs.
- C. Ask about any skin colour changes that occur in response to cold.
- D. Assess for unilateral swelling, redness, and tenderness of either leg.
Correct Answer: A
Rationale: The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin colour that occur in response to cold are consistent with Raynaud's phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness point to venous thromboembolism (VTE).
A patient asks the nurse if there are any natural products that would decrease anticoagulant effects. The nurse tells the patient that which of the following natural products causes a decrease in anticoagulant effects?
- A. Horse chestnut
- B. Licorice root
- C. Turmeric
- D. Green tea
Correct Answer: D
Rationale: Green tea is a natural product that would decrease anticoagulant effects. Horse chestnut, licorice root, and turmeric are natural products that would increase anticoagulant effects.