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Chapter 30: Assessment and Management of Patients With Vascular
Disorders and Problems of Peripheral Circulation
1.
The nurse is taking a health history of a new patient. The patient reports experiencing pain in his left
lower leg and foot when walking. This pain is relieved with rest. The nurse notes that the left lower leg is
slightly edematous and is hairless. When planning this patients subsequent care, the nurse should most
likely address what health problem?
A)
Coronary artery disease (CAD)
B)
Intermittent claudication
C)
Arterial embolus
D)
Raynauds disease
Ans:
B
Feedback:
A muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise
or activity and relieved by rest is experienced by patients with peripheral arterial insufficiency. Referred
to as intermittent claudication, this pain is caused by the inability of the arterial system to provide
adequate blood flow to the tissues in the face of increased demands for nutrients and oxygen during
exercise. The nurse would not suspect the patient has CAD, arterial embolus, or Raynauds disease; none
of these health problems produce this cluster of signs and symptoms.
2.
While assessing a patient the nurse notes that the patients ankle-brachial index (ABI) of the right leg is
0.40. How should the nurse best respond to this assessment finding?
A)
Assess the patients use of over-the-counter dietary supplements.
B)
Implement interventions relevant to arterial narrowing.
C)
Encourage the patient to increase intake of foods high in vitamin K.
D)
Adjust the patients activity level to accommodate decreased coronary output.
Ans:
B
Feedback:
ABI is used to assess the degree of stenosis of peripheral arteries. An ABI of less than 1.0 indicates
possible claudication of the peripheral arteries. It does not indicate inadequate coronary output. There is
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no direct indication for changes in vitamin K intake and OTC medications are not likely causative.
3.
The nurse is providing care for a patient who has just been diagnosed with peripheral arterial occlusive
disease (PAD). What assessment finding is most consistent with this diagnosis?
A)
Numbness and tingling in the distal extremities
B)
Unequal peripheral pulses between extremities
C)
Visible clubbing of the fingers and toes
D)
Reddened extremities with muscle atrophy
Ans:
B
Feedback:
PAD assessment may manifest as unequal pulses between extremities, with the affected leg cooler and
paler than the unaffected leg. Intermittent claudication is far more common than sensations of numbness
and tingling. Clubbing and muscle atrophy are not associated with PAD.
4.
The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the
admission assessment that the patient takes oral contraceptives. Consequently, the nurses postoperative
plan of care should include what intervention?
A)
Early ambulation and leg exercises
B)
Cessation of the oral contraceptives until 3 weeks postoperative
C)
Doppler ultrasound of peripheral circulation twice daily
D)
Dependent positioning of the patients extremities when at rest
Ans:
A
Feedback:
Oral contraceptive use increases blood coagulability; with bed rest, the patient may be at increased risk
of developing deep vein thrombosis. Leg exercises and early ambulation are among the interventions
that address this risk. Assessment of peripheral circulation is important, but Doppler ultrasound may not
be necessary to obtain these data. Dependent positioning increases the risk of venous thromboembolism
(VTE). Contraceptives are not normally discontinued to address the risk of VTE in the short term.
5.
A nurse is creating an education plan for a patient with venous insufficiency. What measure should the
nurse include in the plan?
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
A)
Avoiding tight-fitting socks.
B)
Limit activity whenever possible.
C)
Sleep with legs in a dependent position.
D)
Avoid the use of pressure stockings.
Ans:
A
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Feedback:
Measures taken to prevent complications include avoiding tight-fitting socks and panty girdles;
maintaining activities, such as walking, sleeping with legs elevated, and using pressure stockings. Not
included in the teaching plan for venous insufficiency would be reducing activity, sleeping with legs
dependent, and avoiding pressure stockings. Each of these actions exacerbates venous insufficiency.
6.
The nurse is caring for a patient with a large venous leg ulcer. What intervention should the nurse
implement to promote healing and prevent infection?
A)
Provide a high-calorie, high-protein diet.
B)
Apply a clean occlusive dressing once daily and whenever soiled.
C)
Irrigate the wound with hydrogen peroxide once daily.
D)
Apply an antibiotic ointment on the surrounding skin with each dressing change.
Ans:
A
Feedback:
Wound healing is highly dependent on adequate nutrition. The diet should be sufficiently high in calories
and protein. Antibiotic ointments are not normally used on the skin surrounding a leg ulcer and
occlusive dressings can exacerbate impaired blood flow. Hydrogen peroxide is not normally used
because it can damage granulation tissue.
7.
The nurse is caring for a patient who returned from the tropics a few weeks ago and who sought care
with signs and symptoms of lymphedema. The nurses plan of care should prioritize what nursing
diagnosis?
A)
Risk for infection related to lymphedema
B)
Disturbed body image related to lymphedema
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
C)
Ineffective health maintenance related to lymphedema
D)
Risk for deficient fluid volume related to lymphedema
Ans:
A
586
Feedback:
Lymphedema, which is caused by accumulation of lymph in the tissues, constitutes a significant risk for
infection. The patients body image is likely to be disturbed, and the nurse should address this, but
infection is a more significant threat to the patients physiological well-being. Lymphedema is unrelated
to ineffective health maintenance and deficient fluid volume is not a significant risk.
8.
An occupational health nurse is providing an educational event and has been asked by an administrative
worker about the risk of varicose veins. What should the nurse suggest as a proactive preventative
measure for varicose veins?
A)
Sit with crossed legs for a few minutes each hour to promote relaxation.
B)
Walk for several minutes every hour to promote circulation.
C)
Elevate the legs when tired.
D)
Wear snug-fitting ankle socks to decrease edema.
Ans:
B
Feedback:
A proactive approach to preventing varicose veins would be to walk for several minutes every hour to
promote circulation. Sitting with crossed legs may promote relaxation, but it is contraindicated for
patients with, or at risk for, varicose veins. Elevating the legs only helps blood passively return to the
heart and does not help maintain the competency of the valves in the veins. Wearing tight ankle socks is
contraindicated for patients with, or at risk for, varicose veins; socks that are below the muscles of the
calf do not promote venous return, the socks simply capture the blood and promote venous stasis.
9.
A patient comes to the walk-in clinic with complaints of pain in his foot following stepping on a roofing
nail 4 days ago. The patient has a visible red streak running up his foot and ankle. What health problem
should the nurse suspect?
A)
Cellulitis
B)
Local inflammation
C)
Elephantiasis
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
D)
Lymphangitis
Ans:
D
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Feedback:
Lymphangitis is an acute inflammation of the lymphatic channels. It arises most commonly from a focus
of infection in an extremity. Usually, the infectious organism is hemolytic streptococcus. The
characteristic red streaks that extend up the arm or the leg from an infected wound outline the course of
the lymphatic vessels as they drain. Cellulitis is caused by bacteria, which cause a generalized edema in
the subcutaneous tissues surrounding the affected area. Local inflammation would not present with red
streaks in the lymphatic channels. Elephantiasis is transmitted by mosquitoes that carry parasitic worm
larvae; the parasites obstruct the lymphatic channels and results in gross enlargement of the limbs.
10. The triage nurse in the ED is assessing a patient who has presented with complaint of pain and swelling
in her right lower leg. The patients pain became much worse last night and appeared along with fever,
chills, and sweating. The patient states, I hit my leg on the car door 4 or 5 days ago and it has been sore
ever since. The patient has a history of chronic venous insufficiency. What intervention should the nurse
anticipate for this patient?
A)
Platelet transfusion to treat thrombocytopenia
B)
Warfarin to treat arterial insufficiency
C)
Antibiotics to treat cellulitis
D)
Heparin IV to treat VTE
Ans:
C
Feedback:
Cellulitis is the most common infectious cause of limb swelling. The signs and symptoms include acute
onset of swelling, localized redness, and pain; it is frequently associated with systemic signs of fever,
chills, and sweating. The patient may be able to identify a trauma that accounts for the source of
infection. Thrombocytopenia is a loss or decrease in platelets and increases a patients risk of bleeding;
this problem would not cause these symptoms. Arterial insufficiency would present with ongoing pain
related to activity. This patient does not have signs and symptoms of VTE.
11. A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of HF and
peripheral arterial disease (PAD). At present the patient is unable to stand or ambulate. The nurse should
implement measures to prevent what complication?
A)
Aoritis
B)
Deep vein thrombosis
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
C)
Thoracic aortic aneurysm
D)
Raynauds disease
Ans:
B
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Feedback:
Although the exact cause of venous thrombosis remains unclear, three factors, known as Virchows triad,
are believed to play a significant role in its development: stasis of blood (venous stasis), vessel wall
injury, and altered blood coagulation. In this womans case, she has venous stasis from immobility,
vessel wall injury from PAD, and altered blood coagulation from HF. The cause of aoritis is unknown,
but it has no direct connection to HF, PAD, or mobility issues. The greatest risk factors for thoracic
aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to HF, PAD, or
mobility issues. Raynauds disease is a disorder that involves spasms of blood vessels and, again, no
direct connection to HF, PAD, or mobility issues.
12. A nurse is admitting a 45-year-old man to the medical unit who has a history of PAD. While providing
his health history, the patient reveals that he smokes about two packs of cigarettes a day, has a history of
alcohol abuse, and does not exercise. What would be the priority health education for this patient?
A)
The lack of exercise, which is the main cause of PAD.
B)
The likelihood that heavy alcohol intake is a significant risk factor for PAD.
C)
Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD.
D)
Alcohol suppresses the immune system, creates high glucose levels, and may cause PAD.
Ans:
C
Feedback:
Tobacco is powerful vasoconstrictor; its use with PAD is highly detrimental, and patients are strongly
advised to stop using tobacco. Sedentary lifestyle is also a risk factor, but smoking is likely a more
significant risk factor that the nurse should address. Alcohol use is less likely to cause PAD, although it
carries numerous health risks.
13. A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency. One of the
nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised
circulation. What is the most appropriate intervention for this diagnosis?
A)
Elevate his legs and arms above his heart when resting.
B)
Encourage the patient to engage in a moderate amount of exercise.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
C)
Encourage extended periods of sitting or standing.
D)
Discourage walking in order to limit pain.
Ans:
B
589
Feedback:
The nursing diagnosis of altered peripheral tissue perfusion related to compromised circulation requires
interventions that focus on improving circulation. Encouraging the patient to engage in a moderate
amount of exercise serves to improve circulation. Elevating his legs and arms above his heart when
resting would be passive and fails to promote circulation. Encouraging long periods of sitting or
standing would further compromise circulation. The nurse should encourage, not discourage, walking to
increase circulation and decrease pain.
14. The nurse is caring for a 72-year-old patient who is in cardiac rehabilitation following heart surgery. The
patient has been walking on a regular basis for about a week and walks for 15 minutes 3 times a day. The
patient states that he is having a cramp-like pain in the legs every time he walks and that the pain gets
better when I rest. The patients care plan should address what problem?
A)
Decreased mobility related to VTE
B)
Acute pain related to intermittent claudication
C)
Decreased mobility related to venous insufficiency
D)
Acute pain related to vasculitis
Ans:
B
Feedback:
Intermittent claudication presents as a muscular, cramp-type pain in the extremities consistently
reproduced with the same degree of exercise or activity and relieved by rest. Patients with peripheral
arterial insufficiency often complain of intermittent claudication due to a lack of oxygen to muscle
tissue. Venous insufficiency presents as a disorder of venous blood reflux and does not present with
cramp-type pain with exercise. Vasculitis is an inflammation of the blood vessels and presents with
weakness, fever, and fatigue, but does not present with cramp-type pain with exercise. The pain
associated with VTE does not have this clinical presentation.
15. A nurse in the rehabilitation unit is caring for an older adult patient who is in cardiac rehabilitation
following an MI. The nurses plan of care calls for the patient to walk for 10 minutes 3 times a day. The
patient questions the relationship between walking and heart function. How should the nurse best reply?
A)
The arteries in your legs constrict when you walk and allow the blood to move faster and with
more pressure on the tissue.
B)
Walking increases your heart rate and blood pressure. Therefore your heart is under less stress.
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C)
Walking helps your heart adjust to your new arteries and helps build your self-esteem.
D)
When you walk, the muscles in your legs contract and pump the blood in your veins back toward
your heart, which allows more blood to return to your heart.
Ans:
D
Feedback:
Veins, unlike arteries, are equipped with valves that allow blood to move against the force of gravity.
The legs have one-way bicuspid valves that prevent blood from seeping backward as it moves forward
by the muscles in our legs pressing on the veins as we walk and increasing venous return. Leg arteries do
constrict when walking, which allows the blood to move faster and with more pressure on the tissue, but
the greater concern is increasing the flow of venous blood to the heart. Walking increases, not decreases,
the heart pumping ability, which increases heart rate and blood pressure and the hearts ability to manage
stress. Walking does help the heart adjust to new arteries and may enhance self-esteem, but the patient
had an MIthere are no new arteries.
16. The nurse is caring for a patient who is admitted to the medical unit for the treatment of a venous ulcer
in the area of her lateral malleolus that has been unresponsive to treatment. What is the nurse most likely
to find during an assessment of this patients wound?
A)
Hemorrhage
B)
Heavy exudate
C)
Deep wound bed
D)
Pale-colored wound bed
Ans:
B
Feedback:
Venous ulcerations in the area of the medial or lateral malleolus (gaiter area) are typically large,
superficial, and highly exudative. Venous hypertension causes extravasation of blood, which discolors
the area of the wound bed. Bleeding is not normally present.
17. The nurse is preparing to administer warfarin (Coumadin) to a client with deep vein thrombophlebitis
(DVT). Which laboratory value would most clearly indicate that the patients warfarin is at therapeutic
levels?
A)
Partial thromboplastin time (PTT) within normal reference range
B)
Prothrombin time (PT) eight to ten times the control
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
C)
International normalized ratio (INR) between 2 and 3
D)
Hematocrit of 32%
Ans:
C
591
Feedback:
The INR is most often used to determine if warfarin is at a therapeutic level; an INR of 2 to 3 is
considered therapeutic. Warfarin is also considered to be at therapeutic levels when the clients PT is 1.5
to 2 times the control. Higher values indicate increased risk of bleeding and hemorrhage, whereas lower
values indicate increased risk of blood clot formation. Heparin, not warfarin, prolongs PTT. Hematocrit
does not provide information on the effectiveness of warfarin; however, a falling hematocrit in a client
taking warfarin may be a sign of hemorrhage.
18. The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain whenever she walks
several blocks. The patient has type 1 diabetes and has smoked a pack of cigarettes every day for the
past 40 years. The physician diagnoses intermittent claudication. The nurse should provide what
instruction about long-term care to the client?
A)
Be sure to practice meticulous foot care.
B)
Consider cutting down on your smoking.
C)
Reduce your activity level to accommodate your limitations.
D)
Try to make sure you eat enough protein.
Ans:
A
Feedback:
The patient with peripheral vascular disease or diabetes should receive education or reinforcement about
skin and foot care. Intermittent claudication and other chronic peripheral vascular diseases reduce
oxygenation to the feet, making them susceptible to injury and poor healing; therefore, meticulous foot
care is essential. The patient should stop smokingnot just cut downbecause nicotine is a vasoconstrictor.
Daily walking benefits the patient with intermittent claudication. Increased protein intake will not
alleviate the patients symptoms.
19. A patient who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit.
Which assessments should the nurse perform during the first postoperative day?
A)
Assess pulse of affected extremity every 15 minutes at first.
B)
Palpate the affected leg for pain during every assessment.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
C)
Assess the patient for signs and symptoms of compartment syndrome every 2 hours.
D)
Perform Doppler evaluation once daily.
Ans:
A
592
Feedback:
The primary objective in the postoperative period is to maintain adequate circulation through the arterial
repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor
function of the affected extremity are checked and compared with those of the other extremity; these
values are recorded initially every 15 minutes and then at progressively longer intervals if the patients
status remains stable. Doppler evaluations should be performed every 2 hours. Pain is regularly assessed,
but palpation is not the preferred method of performing this assessment. Compartment syndrome results
from the placement of a cast, not from vascular surgery.
20. You are caring for a patient who is diagnosed with Raynauds phenomenon. The nurse should plan
interventions to address what nursing diagnosis?
A)
Chronic pain
B)
Ineffective tissue perfusion
C)
Impaired skin integrity
D)
Risk for injury
Ans:
B
Feedback:
Raynauds phenomenon is a form of intermittent arteriolar vasoconstriction resulting in inadequate tissue
perfusion. This results in coldness, pain, and pallor of the fingertips or toes. Pain is typically intermittent
and acute, not chronic, and skin integrity is rarely at risk. In most cases, the patient is not at a high risk
for injury.
21. A patient presents to the clinic complaining of the inability to grasp objects with her right hand. The
patients right arm is cool and has a difference in blood pressure of more than 20 mm Hg compared with
her left arm. The nurse should expect that the primary care provider may diagnose the woman with what
health problem?
A)
Lymphedema
B)
Raynauds phenomenon
C)
Upper extremity arterial occlusive disease
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
D)
Upper extremity VTE
Ans:
C
593
Feedback:
The patient with upper extremity arterial occlusive disease typically complains of arm fatigue and pain
with exercise (forearm claudication) and inability to hold or grasp objects (e.g., combing hair, placing
objects on shelves above the head) and, occasionally, difficulty driving. Assessment findings include
coolness and pallor of the affected extremity, decreased capillary refill, and a difference in arm blood
pressures of more than 20 mm Hg. These symptoms are not closely associated with Raynauds or
lymphedema. The upper extremities are rare sites for VTE.
22. A nurse working in a long-term care facility is performing the admission assessment of a newly
admitted, 85-year-old resident. During inspection of the residents feet, the nurse notes that she appears to
have early evidence of gangrene on one of her great toes. The nurse knows that gangrene in the elderly is
often the first sign of what?
A)
Chronic venous insufficiency
B)
Raynauds phenomenon
C)
VTE
D)
PAD
Ans:
D
Feedback:
In elderly people, symptoms of PAD may be more pronounced than in younger people. In elderly
patients who are inactive, gangrene may be the first sign of disease. Venous insufficiency does not
normally manifest with gangrene. Similarly, VTE and Raynauds phenomenon do not cause the ischemia
that underlies gangrene.
23. The prevention of VTE is an important part of the nursing care of high-risk patients. When providing
patient teaching for these high-risk patients, the nurse should advise lifestyle changes, including which
of the following? Select all that apply.
A)
High-protein diet
B)
Weight loss
C)
Regular exercise
D)
Smoking cessation
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
E)
Calcium and vitamin D supplementation
Ans:
B, C, D
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Feedback:
Patients at risk for VTE should be advised to make lifestyle changes, as appropriate, which may include
weight loss, smoking cessation, and regular exercise. Increased protein intake and supplementation with
vitamin D and calcium do not address the main risk factors for VTE.
24. The nurse is caring for an acutely ill patient who is on anticoagulant therapy. The patient has a
comorbidity of renal insufficiency. How will this patients renal status affect heparin therapy?
A)
Heparin is contraindicated in the treatment of this patient.
B)
Heparin may be administered subcutaneously, but not IV.
C)
Lower doses of heparin are required for this patient.
D)
Coumadin will be substituted for heparin.
Ans:
C
Feedback:
If renal insufficiency exists, lower doses of heparin are required. Coumadin cannot be safely and
effectively used as a substitute and there is no contraindication for IV administration.
25. The nurse is assessing a woman who is pregnant at 27 weeks gestation. The patient is concerned about
the recent emergence of varicose veins on the backs of her calves. What is the nurses best response?
A)
Facilitate a referral to a vascular surgeon.
B)
Assess the patients ankle-brachial index (ABI) and perform Doppler ultrasound testing.
C)
Encourage the patient to increase her activity level.
D)
Teach the patient that circulatory changes during pregnancy frequently cause varicose veins.
Ans:
D
Feedback:
Pregnancy may cause varicosities because of hormonal effects related to decreased venous outflow,
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increased pressure by the gravid uterus, and increased blood volume. In most cases, no intervention or
referral is necessary. This finding is not an indication for ABI assessment and increased activity will not
likely resolve the problem.
26. Graduated compression stockings have been prescribed to treat a patients venous insufficiency. What
education should the nurse prioritize when introducing this intervention to the patient?
A)
The need to take anticoagulants concurrent with using compression stockings
B)
The need to wear the stockings on a one day on, one day off schedule
C)
The importance of wearing the stockings around the clock to ensure maximum benefit
D)
The importance of ensuring the stockings are applied evenly with no pressure points
Ans:
D
Feedback:
Any type of stocking can inadvertently become a tourniquet if applied incorrectly (i.e., rolled tightly at
the top). In such instances, the stockings produce rather than prevent stasis. For ambulatory patients,
graduated compression stockings are removed at night and reapplied before the legs are lowered from
the bed to the floor in the morning. They are used daily, not on alternating days. Anticoagulants are not
always indicated in patients who are using compression stockings.
27. The nurse caring for a patient with a leg ulcer has finished assessing the patient and is developing a
problem list prior to writing a plan of care. What major nursing diagnosis might the care plan include?
A)
Risk for disuse syndrome
B)
Ineffective health maintenance
C)
Sedentary lifestyle
D)
Imbalanced nutrition: less than body requirements
Ans:
D
Feedback:
Major nursing diagnoses for the patient with leg ulcers may include imbalanced nutrition: less than body
requirements, related to increased need for nutrients that promote wound healing. Risk for disuse
syndrome is a state in which an individual is at risk for deterioration of body systems owing to
prescribed or unavoidable musculoskeletal inactivity. A leg ulcer will affect activity, but rarely to this
degree. Leg ulcers are not necessarily a consequence of ineffective health maintenance or sedentary
lifestyle.
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28. How should the nurse best position a patient who has leg ulcers that are venous in origin?
A)
Keep the patients legs flat and straight.
B)
Keep the patients knees bent to 45-degree angle and supported with pillows.
C)
Elevate the patients lower extremities.
D)
Dangle the patients legs over the side of the bed.
Ans:
C
Feedback:
Positioning of the legs depends on whether the ulcer is of arterial or venous origin. With venous
insufficiency, dependent edema can be avoided by elevating the lower extremities. Dangling the patients
legs and applying pillows may further compromise venous return.
29. A patient with advanced venous insufficiency is confined following orthopedic surgery. How can the
nurse best prevent skin breakdown in the patients lower extremities?
A)
Ensure that the patients heels are protected and supported.
B)
Closely monitor the patients serum albumin and prealbumin levels.
C)
Perform gentle massage of the patients lower legs, as tolerated.
D)
Perform passive range-of-motion exercises once per shift.
Ans:
A
Feedback:
If the patient is on bed rest, it is important to relieve pressure on the heels to prevent pressure
ulcerations, since the heels are among the most vulnerable body regions. Monitoring blood work does
not directly prevent skin breakdown, even though albumin is related to wound healing. Massage is not
normally indicated and may exacerbate skin breakdown. Passive range- of-motion exercises do not
directly reduce the risk of skin breakdown.
30. The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers.
The nurses assessment should include which of the following components? Select all that apply.
A)
Location and type of pain
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
B)
Apical heart rate
C)
Bilateral comparison of peripheral pulses
D)
Comparison of temperature in the patients legs
E)
Identification of mobility limitations
Ans:
A, C, D, E
597
Feedback:
A careful nursing history and assessment are important. The extent and type of pain are carefully
assessed, as are the appearance and temperature of the skin of both legs. The quality of all peripheral
pulses is assessed, and the pulses in both legs are compared. Any limitation of mobility and activity that
results from vascular insufficiency is identified. Not likely is there any direct indication for assessment
of apical heart rate, although peripheral pulses must be assessed.
31. A nurse on a medical unit is caring for a patient who has been diagnosed with lymphangitis. When
reviewing this patients medication administration record, the nurse should anticipate which of the
following?
A)
Coumadin (warfarin)
B)
Lasix (furosemide)
C)
An antibiotic
D)
An antiplatelet aggregator
Ans:
C
Feedback:
Lymphangitis is an acute inflammation of the lymphatic channels caused by an infectious process.
Antibiotics are always a component of treatment. Diuretics are of nominal use. Anticoagulants and
antiplatelet aggregators are not indicated in this form of infection.
32. A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of lower leg
pain. On inspection, the nurse observes that the patients left leg is visibly swollen and reddened. What is
the nurses most appropriate action?
A)
Administer a PRN dose of subcutaneous heparin.
B)
Inform the physician that the patient has signs and symptoms of VTE.
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
C)
Mobilize the patient promptly to dislodge any thrombi in the patients lower leg.
D)
Massage the patients lower leg to temporarily restore venous return.
Ans:
B
598
Feedback:
VTE requires prompt medical follow-up. Heparin will not dissolve an established clot. Massaging the
patients leg and mobilizing the patient would be contraindicated because they would dislodge the clot,
possibly resulting in a pulmonary embolism.
33. A nurse is closely monitoring a patient who has recently been diagnosed with an abdominal aortic
aneurysm. What assessment finding would signal an impending rupture of the patients aneurysm?
A)
Sudden increase in blood pressure and a decrease in heart rate
B)
Cessation of pulsating in an aneurysm that has previously been pulsating visibly
C)
Sudden onset of severe back or abdominal pain
D)
New onset of hemoptysis
Ans:
C
Feedback:
Signs of impending rupture include severe back or abdominal pain, which may be persistent or
intermittent. Impending rupture is not typically signaled by increased blood pressure, bradycardia,
cessation of pulsing, or hemoptysis.
34. A nurse is reviewing the physiological factors that affect a patients cardiovascular health and tissue
oxygenation. What is the systemic arteriovenous oxygen difference?
A)
The average amount of oxygen removed by each organ in the body
B)
The amount of oxygen removed from the blood by the heart
C)
The amount of oxygen returning to the lungs via the pulmonary artery
D)
The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood
Ans:
D
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
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Feedback:
The average amount of oxygen removed collectively by all of the body tissues is about 25%. This means
that the blood in the vena cava contains about 25% less oxygen than aortic blood. This is known as the
systemic arteriovenous oxygen difference. The other answers do not apply.
35. The nurse is evaluating a patients diagnosis of arterial insufficiency with reference to the adequacy of
the patients blood flow. On what physiological variables does adequate blood flow depend? Select all
that apply.
A)
Efficiency of heart as a pump
B)
Adequacy of circulating blood volume
C)
Ratio of platelets to red blood cells
D)
Size of red blood cells
E)
Patency and responsiveness of the blood vessels
Ans:
A, B, E
Feedback:
Adequate blood flow depends on the efficiency of the heart as a pump, the patency and responsiveness
of the blood vessels, and the adequacy of circulating blood volume. Adequacy of blood flow does not
primarily depend on the size of red cells or their ratio to the number of platelets.
36. A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the pulse in the
patients left foot. How should the nurse proceed with assessment?
A)
Have the primary care provider order a CT.
B)
Apply a tourniquet for 3 to 5 minutes and then reassess.
C)
Elevate the extremity and attempt to palpate the pulses.
D)
Use Doppler ultrasound to identify the pulses.
Ans:
D
Feedback:
When pulses cannot be reliably palpated, a hand-held continuous wave (CW) Doppler ultrasound device
may be used to hear (insonate) the blood flow in vessels. CT is not normally warranted and the
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
600
application of a tourniquet poses health risks and will not aid assessment. Elevating the extremity would
make palpation more difficult.
37. A medical nurse has admitted four patients over the course of a 12-hour shift. For which patient would
assessment of ankle-brachial index (ABI) be most clearly warranted?
A)
A patient who has peripheral edema secondary to chronic heart failure
B)
An older adult patient who has a diagnosis of unstable angina
C)
A patient with poorly controlled type 1 diabetes who is a smoker
D)
A patient who has community-acquired pneumonia and a history of COPD
Ans:
C
Feedback:
Nurses should perform a baseline ABI on any patient with decreased pulses or any patient 50 years of
age or older with a history of diabetes or smoking. The other answers do not apply.
38. An older adult patient has been treated for a venous ulcer and a plan is in place to prevent the occurrence
of future ulcers. What should the nurse include in this plan?
A)
Use of supplementary oxygen to aid tissue oxygenation
B)
Daily use of normal saline compresses on the lower limbs
C)
Daily administration of prophylactic antibiotics
D)
A high-protein diet that is rich in vitamins
Ans:
D
Feedback:
A diet that is high in protein, vitamins C and A, iron, and zinc is encouraged to promote healing and
prevent future ulcers. Prophylactic antibiotics and saline compresses are not used to prevent ulcers.
Oxygen supplementation does not prevent ulcer formation.
39. A 79-year-old man is admitted to the medical unit with digital gangrene. The man states that his
problems first began when he stubbed his toe going to the bathroom in the dark. In addition to this
trauma, the nurse should suspect that the patient has a history of what health problem?
A)
Raynauds phenomenon
Test Bank - Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
B)
CAD
C)
Arterial insufficiency
D)
Varicose veins
Ans:
C
601
Feedback:
Arterial insufficiency may result in gangrene of the toe (digital gangrene), which usually is caused by
trauma. The toe is stubbed and then turns black. Raynauds, CAD and varicose veins are not the usual
causes of digital gangrene in the elderly.
40. When assessing venous disease in a patients lower extremities, the nurse knows that what test will most
likely be ordered?
A)
Duplex ultrasonography
B)
Echocardiography
C)
Positron emission tomography (PET)
D)
Radiography
Ans:
A
Feedback:
Duplex ultrasound may be used to determine the level and extent of venous disease as well as its
chronicity. Radiographs (x-rays), PET scanning, and echocardiography are never used for this purpose
as they do not allow visualization of blood flow.