Nokea
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.
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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.
The nurse is providing teaching to a patient with a venous ulcer on the right lower leg. Which of the following patient statements indicates a need for further teaching?
- A. I will put on my support stockings before I get out of bed in the morning.
- B. I will take an antibiotic for a few days to prevent infection of the ulcer.
- C. I will eat more meat and other high-protein foods.
- D. I will apply a compression dressing every evening before I go to bed.
Correct Answer: B
Rationale: Compression of the leg is essential to healing of venous ulcers in patients with chronic venous insufficiency. High dietary intake of protein, rather than carbohydrates, is needed. Prophylactic antibiotics are not routinely used for venous ulcers. Moist environment dressings are used to hasten wound healing. Applying a compression dressing only in the evening is insufficient; it should be worn consistently to promote healing.
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 caring for a patient with peripheral artery disease who is Aspirin intolerant. Which of the following medications should the nurse anticipate the health care provider prescribing for the patient related to this intolerance?
- A. Pentoxifylline
- B. Clopidogrel
- C. Ramipril
- D. Warfarin
Correct Answer: B
Rationale: For patients who are Aspirin intolerant, clopidogrel (75 mg/day) is indicated. Pentoxifylline is used to treat intermittent claudication. Ramipril is an ACE inhibitor. Warfarin is an anticoagulant and is not recommended for the prevention of coronary artery disease in patients with PAD.
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.