Nokea
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.
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A patient tells the health care provider about experiencing cold, numb fingers when running during the winter and is diagnosed with Raynaud's phenomenon. Based upon this diagnosis, the patient should be investigated for which of the following conditions?
- A. Hypertension
- B. Hyperlipidemia
- C. Autoimmune disorders
- D. Coronary artery disease
Correct Answer: C
Rationale: Secondary Raynaud's phenomenon may occur in conjunction with autoimmune diseases such as rheumatoid arthritis, and patients should be screened for autoimmune disorders. Raynaud's phenomenon is not associated with hyperlipidemia, hypertension, or coronary artery disease.
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).
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.
Immediately after repair of an abdominal aortic aneurysm, a patient has absent popliteal, posterior tibial, and dorsalis pedis pulses. The legs are cool and mottled. Which of the following actions should the nurse take first?
- A. Wrap both the legs in warm blankets.
- B. Notify the surgeon and anaesthesiologist.
- C. Document that the pulses are absent and recheck in 30 minutes.
- D. Review the preoperative assessment form for data about the pulses.
Correct Answer: D
Rationale: Many patients with aortic aneurysms also have peripheral arterial disease, so the nurse should check the preoperative assessment to determine whether pulses were present before surgery before notifying the health care providers about the absent pulses. Because the patient's symptoms may indicate graft occlusion or multiple emboli and a possible need to return to surgery, it is not appropriate to wait 30 minutes before taking action. Warm blankets will not improve the circulation to the patient's legs.
Which of the following nursing actions should be included in the plan of care for a patient who has had endovascular repair of an abdominal aortic aneurysm?
- A. Record hourly chest tube drainage.
- B. Monitor fluid intake and urine output.
- C. Check the abdominal wound for redness or swelling.
- D. Teach the reason for a prolonged rehabilitation process.
Correct Answer: B
Rationale: Because renal artery occlusion can occur after endovascular repair, the nurse should monitor parameters of renal function such as intake and output. Chest tubes will not be needed for endovascular surgery, the recovery period will be short, and there will not be an abdominal wound.