Nokea
The nurse is obtaining a health history from a patient who has a 5-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. Which of the following symptoms should the nurse expect to assess in the patient?
- A. Back or lumbar pain
- B. Difficulty swallowing
- C. Abdominal tenderness
- D. Changes in bowel habits
Correct Answer: B
Rationale: Difficulty swallowing may occur with a thoracic aneurysm because of pressure on the esophagus. The other symptoms will be important to assess for in patients with abdominal aortic aneurysms.
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While working in the outpatient clinic, the nurse notes that the medical record states that a patient has intermittent claudication. Which of the following patient statements is consistent with this information?
- A. When I stand too long, my feet start to swell up.
- B. Sometimes I get tired when I climb a lot of stairs.
- C. My fingers hurt when I go outside in cold weather.
- D. My legs cramp whenever I walk more than a block.
Correct Answer: D
Rationale: Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication. Finger pain associated with cold weather is typical of Raynaud's phenomenon. Fatigue that occurs sometimes with exercise is not typical of intermittent claudication, which is reproducible. Swelling associated with prolonged standing is typical of venous disease.
Which of the following actions by a nurse who is administering fondaparinux to a patient with venous thromboembolism (VTE) indicates that more education about the medication is needed?
- A. The nurse avoids rubbing the injection site after giving the medication.
- B. The nurse injects the medication into the abdominal subcutaneous tissue.
- C. The nurse fails to assess the partial thromboplastin time (PTT) before administration of the medication.
- D. The nurse ejects the air bubble in the syringe before administering the medication.
Correct Answer: D
Rationale: The air bubble is not ejected before giving fondaparinux. The other actions by the nurse are appropriate.
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.
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.
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.