Nokea
The nurse is caring for a patient who is admitted to the medical unit for the treatment of a venous ulcer in the area of her lateral malleolus that has been unresponsive to treatment. What is the nurse most likely to find during an assessment of this patients wound?
- A. Hemorrhage
- B. Heavy exudate
- C. Deep wound bed
- D. Pale-colored wound bed
Correct Answer: B
Rationale: Venous ulcerations in the area of the medial or lateral malleolus (gaiter area) are typically large, superficial, and highly exudative. Venous hypertension causes extravasation of blood, which discolors the area of the wound bed. Bleeding is not normally present.
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A patient with advanced venous insufficiency is confined following orthopedic surgery. How can the nurse best prevent skin breakdown in the patients lower extremities?
- A. Ensure that the patients heels are protected and supported.
- B. Closely monitor the patients serum albumin and prealbumin levels.
- C. Perform gentle massage of the patients lower legs, as tolerated.
- D. Perform passive range-of-motion exercises once per shift.
Correct Answer: A
Rationale: If the patient is on bed rest, it is important to relieve pressure on the heels to prevent pressure ulcerations, since the heels are among the most vulnerable body regions. Monitoring blood work does not directly prevent skin breakdown, even though albumin is related to wound healing. Massage is not normally indicated and may exacerbate skin breakdown. Passive range-of-motion exercises do not directly reduce the risk of skin breakdown.
You are caring for a patient who is diagnosed with Raynauds phenomenon. The nurse should plan interventions to address what nursing diagnosis?
- A. Chronic pain
- B. Ineffective tissue perfusion
- C. Impaired skin integrity
- D. Risk for injury
Correct Answer: B
Rationale: Raynauds phenomenon is a form of intermittent arteriolar vasoconstriction resulting in inadequate tissue perfusion. This results in coldness, pain, and pallor of the fingertips or toes. Pain is typically intermittent and acute, not chronic, and skin integrity is rarely at risk. In most cases, the patient is not at a high risk for injury.
A nurse is creating an education plan for a patient with venous insufficiency. What measure should the nurse include in the plan?
- A. Avoiding tight-fitting socks.
- B. Limit activity whenever possible.
- C. Sleep with legs in a dependent position.
- D. Avoid the use of pressure stockings.
Correct Answer: A
Rationale: Measures taken to prevent complications include avoiding tight-fitting socks and panty girdles; maintaining activities, such as walking, sleeping with legs elevated, and using pressure stockings. Not included in the teaching plan for venous insufficiency would be reducing activity, sleeping with legs dependent, and avoiding pressure stockings. Each of these actions exacerbates venous insufficiency.
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.
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.