Nokea
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.
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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 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.
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 notes bruising and discoloration of the right leg of a patient that has just arrived in the recovery unit from having vein ligation surgery. Which of the following interventions is priority?
- A. Place the patient in the Trendelenburg position.
- B. Contact the health care provider.
- C. Elevate the bed at the knee and put pillows under the feet.
- D. Elevate the legs 15 degrees to limit edema.
Correct Answer: D
Rationale: After vein ligation surgery, the legs should be elevated 15 degrees to limit edema. Placing the patient in the Trendelenburg position will lower the head below heart level, which is not indicated for this patient. Placing pillows under the calf or elevating the bed at the knee may cause blood stasis at the calf level. Bruising and discoloration are expected after vein ligation surgery so there is no need to contact the health care provider at this time.
The nurse is caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair. Which of the following assessment findings is most important to communicate to the health care provider?
- A. Absence of flatus
- B. Loose, bloody stools
- C. Hypotonic bowel sounds
- D. Abdominal pain with palpation
Correct Answer: B
Rationale: Loose, bloody stools at this time may indicate intestinal ischemia or infarction and should be reported immediately because the patient may need an emergency bowel resection. The other findings are normal on the first postoperative day after abdominal surgery.