Nokea
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.
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The nurse is planning expected outcomes for a patient with thromboangiitis obliterans (Buerger's disease). Which of the following outcomes has the highest priority for this patient?
- A. Cessation of smoking
- B. Control of serum lipid levels
- C. Maintenance of appropriate weight
- D. Demonstration of meticulous foot care
Correct Answer: A
Rationale: Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with Buerger's disease. Other therapies have limited success in treatment of this disease.
A patient is admitted to the hospital with a diagnosis of chronic venous insufficiency. Which of the following patient statements is most consistent with this diagnosis?
- A. I can't get my shoes on at the end of the day.
- B. I can never seem to get my feet warm enough.
- C. I wake up during the night because my legs hurt.
- D. I have burning leg pains after I walk three blocks.
Correct Answer: A
Rationale: Because the edema associated with venous insufficiency increases when the patient has been standing, shoes will feel tighter at the end of the day. The other patient statements are characteristic of peripheral artery disease (PAD).
The nurse is developing a teaching plan for a patient newly diagnosed with peripheral artery disease (PAD). Which of the following information should the nurse include?
- A. Exercise only if you do not experience any pain.
- B. It is very important that you stop smoking cigarettes.
- C. Try to keep your legs elevated whenever you are sitting.
- D. Put on support hose early in the day before swelling occurs.
Correct Answer: B
Rationale: Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death. Circulation to the legs will decrease if the legs are elevated. Patients with PAD are taught to exercise to the point of feeling pain, rest, and then resume walking. Support hose are not used for patients with PAD.
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.
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.