52.
3. Clients with Raynaud’s phenomenon should receive routine follow-up to monitor symp- toms and to assess for the development of connec- tive tissue or autoimmune diseases associated with Raynaud’s. Beta blockers are not considered fi rst- line drug therapy. A sympathectomy is considered only in advanced cases. There is no benefi t to an angioplasty, which is used for atherosclerotic vascu- lar disease.CN: Health promotion and maintenance;
CL: Create
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The Client with Thrombophlebitis and Embolus Formation
63.
4. Based on the laboratory fi ndings, pro- thrombin time and INR are at acceptable antico- agulation levels for the treatment of DVT. However, the platelets are below the acceptable level. Clients taking enoxaparin are at risk for thrombocytopenia.Because of the low platelet level, the nurse should withhold the enoxaparin, assess the client for bleeding, and then contact the physician.
CN: Pharmacological and parenteral therapies; CL: Synthesize
64.
2. Acute arterial occlusion is a sudden inter- ruption of blood fl ow. The interruption can be the result of complete or partial obstruction. Acute pain, loss of sensory and motor function, and a pale, mottled, numb extremity are the most dramatic and observable changes that indicate a life-threatening interruption of tissue perfusion. Blood pressure and heart rate changes may be associated with the acute pain episode. Metabolic acidosis is a com- plication of irreversible ischemia. Swelling may result but may also indicate venous stasis or arterial insuffi ciency.CN: Physiological adaptation;
CL: Analyze
65.
1. Venous stasis can increase pain. Therefore, proper positioning in bed or when sitting up in a chair can help promote venous drainage, reduce swelling, and reduce the amount of pain the client might experience. Placing a pillow under the knees causes fl exion of the joint, resulting in a dependent position of the lower leg and causing a decrease in blood fl ow. Fluids are encouraged to maintain normal fl uid and electrolyte balance but do little to relieve pain. Therapeutic massage to the legs is dis- couraged because of the danger of breaking up the clot.CN: Basic care and comfort;
CL: Syntehsize
66.
3. The client is likely suffering from an embolus as a result of abdominal surgery. The nurse should inspect the left leg for color and temperature changes associated with tissue perfusion. Admin- istering pain medication without gathering more information about the pain can mask important signs and symptoms. Although assessing for edema is important, it is not critical to this situation.Encouraging the client to change her position does not adequately address the need for gathering more data.
CN: Reduction of risk potential;
CL: Synthesize (Raynaud’s disease). The client should be encour-
aged to wear gloves when handling frozen foods or ice. The client should immerse the involved extrem- ity in warm water during an episode to promote vasodilation and relaxation of the small arteries that are in spasm. The client can help prevent vasospasm brought on by temperature changes by wearing warm clothes. Living in a cold climate will exacerbate the symptoms.
CN: Health promotion and maintenance;
CL: Synthesize
59.
3. Loose warm clothing should be worn to protect from the cold. Wearing gloves when han- dling cold objects will help prevent vasospasms.Vibrating equipment and typing contribute to vasospasm. Tobacco and caffeine should be avoided.
Elevation will decrease arterial perfusion during vasospasms.
CN: Health promotion and maintenance;
CL: Synthesize
60.
3. Calcium channel blockers are fi rst-line drug therapy for the treatment of vasospasms with Raynaud’s phenomenon when other therapies are ineffective. Cardizem relaxes smooth muscles and improves peripheral perfusion, therefore reducing fi nger numbness. Cardizem decreases heart rate and is used to treat atrial fi brillation, but these are not associated with Raynaud’s. When vasospasms are prevented, an accurate SpO2 can be measured in the affected extremity, however SpO2 is a measure- ment of systemic oxygenation not infl uenced by Cardizem.CN: Pharmacological and parenteral therapies; CL: Evaluate
61.
1. Beta-adrenergic medications block the beta-adrenergic receptors. Therefore, the expected outcome of the medication is to decrease the infl u- ence of the sympathetic nervous system on the blood vessels in the hands. Beta-adrenergic blockers have no analgesic effects. Increasing blood supply to the affected area is an indirect effect of beta-adren- ergic blockers. They do not increase monoamine oxidase, which does not play a role in Raynaud’s disease.CN: Pharmacological and parenteral therapies; CL: Apply
62.
4. Sympathectomy is scheduled only after other treatment alternatives have been explored and have failed. Medication and stress management are benefi cial strategies to prevent advancement of the disease process. If the disease is controlled by medi- cation, there is no reason for surgery.CN: Physiological adaptation; CL: Apply
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71.
4. Thrombophlebitis is an infl ammation of a vein. The underlying etiology involves stasis of blood, increased blood coagulability, and vessel wall injury. The symptoms of thrombophlebitis are pain, swelling, and deep muscle tenderness. Air embolus is a result of air entering the vascular system. Fat embolus is associated with the presence of intracel- lular fat globules in the lung parenchyma and periph- eral circulation after long-bone fractures. Stress frac- tures are associated with the musculoskeletal system.CN: Health promotion and maintenance;
CL: Analyze
72.
3. The fi rst action should be to discontinue the I.V. The nurse should restart the I.V. elsewhere and then apply a warm compress to the affected area. The nurse should administer acetaminophen or an anti-infl ammatory agent only if ordered by the physician. The type of infusion cannot be changed without a physician’s order, and such a change would not help in this case.CN: Reduction of risk potential;
CL: Synthesize
73.
4. Three factors contribute to the formation of venous thrombus and thrombophlebitis: damage to the inner lining of the vein (prolonged pressure), hypercoagulability of the blood, and venous stasis.Bed rest and immobilization are associated with decreased blood fl ow and venous pooling in the lower extremities. Keeping the client in the supine position would not be appropriate. Turning the cli- ent every 1 to 2 hours, passive and active range-of- motion exercises, and use of TED hose help prevent venous stasis in the lower extremities.
CN: Reduction of risk potential;
CL: Create
74.
2. The client demonstrates classic symptoms of DVT, and the nurse should continue to assess the client. Signs and symptoms of an aortic aneurysm include abdominal pain and a pulsating abdomi- nal mass. Clients with drug abuse demonstrate confusion and decreased levels of consciousness.Claudication is an intermittent pain in the leg.
CN: Psychosocial adaptation; CL: Analyze
75.
4. Heparin dosage is usually determined by the physician based on the client’s aPTT and INR lab- oratory values. Therefore, the nurse monitors these values to prevent complications. Administering aspi- rin when the client is on heparin is contraindicated.Green leafy vegetables are high in vitamin K and therefore are not recommended for clients receiving heparin. Monitoring of the client’s PT is done when the client is receiving warfarin sodium (Coumadin).
CN: Pharmacological and parenteral therapies; CL: Create
67.
2. Performing active ankle and foot range-of- motion exercises periodically during the ride home will promote muscular contraction and provide support to the venous system. It is the muscular action that facilitates return of the blood from the lower extremities, especially when in the dependent position. Arm circle exercises will not promote cir- culation in the leg. It is not necessary for the client to elevate her legs as long as she does not occlude blood fl ow to her legs and does her leg exercises. It is not necessary to take an ambulance because the client is able to sit in the car safely.CN: Reduction of risk potential;
CL: Synthesize
68.
3. DVT is commonly associated with venous stasis in the legs when there is a lack of the skel- etal muscle pump that enhances venous return to the heart. When a client is confi ned to bed rest, venous compression occurs because of the position of the lower extremities. This increased pressure causes damage to the intima lining of the veins and causes platelets to adhere to the damaged site.DVT increases the risk that a displaced plaque will become a pulmonary embolus. Arteriosclerosis is hardening of the arteries; aneurysm is the abnormal dilation of a vessel; and varicose veins are swollen, tortuous veins. These are not generally considered causes of pulmonary embolism.
CN: Physiological adaptation; CL: Apply
69.
3. Thrombolytic agents are used for clients with a history of thrombus formation, cerebro- vascular accidents, and chronic atrial fi brillation.The thrombolytic agents act by dissolving emboli.
Thrombolytic agents do not directly improve perfu- sion or increase vascular permeability, nor do they prevent cerebral hemorrhage.
CN: Pharmacological and parenteral therapies; CL: Apply
70.
0.85 mLFirst convert pounds (lb) to kilograms (kg) by using the formula:
1 kg = 2.2 lb [187 lb ÷ 2.2 = 85 kg].
The physician’s order is for the client to receive enoxaparin (Lovenox) 1 mg/kg. Therefore, the client is to receive 85 mg. The desired dose in millili- ters then can be calculated by using the formula of desired dose (D) divided by dose or strength of dose on hand (H) times volume (V).
85 (mg) × 0.3 mL = 25.5 mg/mL 25.5 mg ÷ 30 = 0.85 mL.
CN: Pharmacological and parenteral therapies; CL: Apply
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81.
2. The client is at risk for development of varicose veins. Therefore, prevention is key in the treatment plan. Maintaining ideal body weight is the goal. In order to achieve this, the client should consume a balanced diet and participate in a regu- lar exercise program. Depending on the individual, leg lifts may or may not be an appropriate activ- ity. Performing leg lifts provides muscular activ- ity and should be done more often than every 4 hours. Wearing support hose is helpful. However, the client should not use rubber bands to hold the stockings up.CN: Reduction of risk potential;
CL: Evaluate
82.
1, 2, 4, 5, 6. Clients with resolving DVT being sent home on anticoagulant therapy need instruc- tions about assessing and preventing bleeding episodes and preventing a recurrence of DVT. Blood in the urine (hematuria) is often one of the fi rst symptoms of anticoagulant overdose. Fresh blood in the urine is red; however, blood in the urine may also be a dark smoky color. Daily ambulation is an excellent activity to keep the venous blood circulat- ing and thus to prevent blood clots from forming in the lower extremities. Garlic and ginger increase the bleeding time and should not be used when a client is on anticoagulant therapy. Clients who have had previous DVTs should avoid activities that cause stagnation and pooling of venous blood. Prolonged sitting coupled with change of air pressure without foot or leg exercises or ambulation in the cabin are activities that prevent venous return. Instructing the client about prevention measures is important because clients with DVT are at high risk for pulmo- nary emboli (PE), which can be fatal. The client can be taught risk factors for DVT and PE. In addition, recommendations for prevention of these events also are standard protocol in practice and should be shared with the client for home care purposes. Older adults should be monitored closely for bleeding because the skin becomes thinner and the capillar- ies become more fragile with the aging process.CN: Health promotion and maintenance;
CL: Create
83.
5. Inspect the dressing.
3. Regulate the I.V. infusion.
1. Administer pain medication.
2. Draw blood for laboratory studies.
4. Monitor the pulses.
76.
4. The use of pneumatic compression stock- ings is an intervention used to prevent DVT. Other strategies include early ambulation, leg exercises if the client is confi ned to bed, adequate fl uid intake, and administering anticoagulant medication as ordered. Deep breathing would be encouraged post- operatively, but it does not prevent DVT.CN: Health promotion and maintenance;
CL: Synthesize
77.
4. Risk for impaired skin integrity is the pri- mary nursing diagnosis. With rubor or hyperemia, there is increased blood fl ow to the area, raising fi ltration pressure. As a result, capillary permeability is altered, causing damage to capillary walls. The increased permeability, obstruction of lymphatic drainage, elevation of venous pressure, and decrease in plasma protein osmotic force result in edema. The data do not support the nursing diagnoses of Activity intolerance, Ineffective health maintenance, or Pain.CN: Physiological adaptation;
CL: Analyze
78.
4. The data suggest an increased risk of thrombophlebitis. The risk factors in this situa- tion include abdominal surgery, obesity, and use of estrogen-based oral contraceptives. Risk factors for atherosclerosis include genetics, older age, and a high-cholesterol diet. Risk factors for diabetes include genetics and obesity. Risk factors for vasos- pastic disorders include cold climate, age (16 to 40), and immunologic disorders.CN: Reduction of risk potential;
CL: Analyze
79.
4. The client has varicose veins which are evident by the tortuous, distended veins where blood has pooled. To prevent pooling of the blood, the client should not stand in one place for long periods of time. It is not necessary to use compres- sion devices, but the client could wear support hose if she stands for long periods of time. The client can consider cosmetic surgery to remove the distented veins, but there is not indication that the client should contact the physician at this point in time.The nurse can inspect the client’s feet, but the client is not at risk for ulcers at this time..
CN: Health promotion and maintenance;
CL: Synthesize
80.
3. Secondary varicosities can result from pre- vious thrombophlebitis of the deep femoral veins, with subsequent valvular incompetence. Cerebro- vascular accident, anemia, and transient ischemic attacks are not associated with an increased risk of varicose veins.CN: Health promotion and maintenance;
CL: Analyze
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An elevated heart rate is expected after physical exertion. It is important to monitor urine output following aneurysm surgery, but a urine output of 2,000 mL in 24 hours is adequate following surgery.
CN: Safety and infection control;
CL: Synthesize
88.
3. The primary goal is to prepare the client for emergency surgery. The goal would be to prevent rupture of the aneurysm and potential death. Circu- lation is maintained, unless the aneurysm ruptures.When the client is prepared for surgery, the nurse should place the client in a recumbent position to promote circulation, teach the client about post- operative breathing exercises, and administer pain medication if ordered.
CN: Physiological adaptation;
CL: Synthesize
89.
1. If the aortic arch is involved, there will be a decrease in the blood fl ow to the cerebrum. There- fore, loss of consciousness will be observed. A sud- den loss of consciousness is a primary symptom of rupture and no blood fl ow to the brain. Anxiety is not a sign of aortic valvular insuffi ciency. The end result of decreased cerebral blood fl ow is loss of consciousness, not headache or disorientation.CN: Reduction of risk potential;
CL: Analyze
90.
1. Cardiac tamponade is a life-threatening complication of a dissecting thoracic aneurysm.The sudden, painful “tearing” sensation is typically associated with the sudden release of blood, and the client may experience cardiac arrest. Stroke, pul- monary edema, and myocardial infarction are not common complications of a dissecting aneurysm.
CN: Physiological adaptation; CL: Apply
91.
3. In the preoperative phase, the goal is to pre- vent rupture. The client is placed in a semi-Fowler’s position and in a quiet environment. The systolic blood pressure is maintained at the lowest level the client can tolerate. Anemia, dehydration, and hyperg- lycemia do not put the client at risk for rupture.CN: Health promotion and maintenance;
CL: Analyze
92.
1. Following surgical repair of an aortic aneu- rysm, there is a potential for an alteration in renal perfusion, manifested by decreased urine output.The altered renal perfusion may be related to renal artery embolism, prolonged hypotension, or pro- longed aortic cross-clamping during surgery. Elec- trolyte imbalance, ineffective coping, and wound infection may occur after any surgery and do not present imminent risk for this client.
CN: Physiological adaptation;
CL: Analyze The nurse should fi rst monitor the popliteal and
pedal pulses in the affected extremity after arterial embolectomy. Monitoring peripheral pulses below the site of occlusion checks the arterial circulation in the involved extremity. The nurse should next inspect the dressing to be sure that the client is not bleeding at the surgical site. The nurse should next regulate the I.V. infusion to prevent fl uid overload.
Then the nurse should assess pain and administer pain medications as ordered. Last, the nurse can obtain blood for laboratory studies.
CN: Physiological adaptation;
CL: Synthesize
The Client with an Aneurysm
84.
4. The underlying pathophysiology in this client is atherosclerosis. The fi ndings from the assessment indicate the risk factors of smoking and high blood pressure. Therefore, tissue perfusion is a priority for health promoting education. The data do not support education that focuses on food or fl uid intake. Although edema is a potential problem and could contribute to poor skin integrity, the edema will likely be resolved by the aneurysm repair.CN: Physiological adaptation;
CL: Synthesize
85.
1. The size of the thoracic aneurysm is rather large, so the nurse should anticipate rupture. A sud- den incidence of pain may indicate leakage or rup- ture. The blood pressure and heart rate will provide useful information in assessing for hypovolemic shock. The nurse needs more data before initiating other interventions. After assessment of vital signs, neurologic status, and pain, the nurse can then con- tact the physician. Administering lactated Ringer’s solution would require a physician’s order.CN: Physiological adaptation;
CL: Synthesize
86.
2. The symptoms suggest an abdominal aortic aneurysm that is leaking or rupturing. An I.V. should be inserted for immediate volume replacement. With hypovolemia, the urine output will be diminished.Repositioning may potentiate the problem. A naso- gastric tube may be considered with severe nausea and vomiting to decompress the stomach.
CN: Physiological adaptation;
CL: Synthesize
87.
4. One of the complications of a thoracoab- dominal aneurysm repair is spinal cord injury. There- fore, it is important for the nurse to assess for signs and symptoms of neurologic changes at and below the site where the aneurysm was repaired. The client is expected to have moderate pain following surgery.Billings_Part 2_Chap 3_Test 02.indd 366
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98.
4. Providing an over-the-bed cradle will decrease the amount of pressure that the linens exert upon the lower extremity and prevent further tissue breakdown. Administering prescribed analge- sics would be an intervention for reducing the pain.Applying lanolin lotions to the left ankle ulcer will not promote healing. Encouraging the client to sit up in a chair four times per day is an intervention to promote activity. The nurse would elevate the involved extremity while the client is sitting up to reduce venous stasis and capillary pressure.
CN: Health promotion and maintenance;
CL: Synthesize
99.
2. The nurse should fi rst determine what the client means when he says he will apply an herb mixture to his ulcer. The nurse should then encour- age the client to consult the physician because home remedies may be benefi cial or may interfere with the medical treatment plan. In many cultures, home remedies are commonly used and may be helpful. The nurse must be sensitive to these traditions and cul- tural beliefs. The other statements demonstrate that the client understands the plan of care for his ulcer.CN: Health promotion and maintenance;
CL: Evaluate
The Client with Peripheral Arterial Occlusive Disease
100.
1. The ABI test is a noninvasive test that compares the systolic blood pressure in the arm with that of the ankle. It may be done before or after exercise. The client’s highest brachial systolic pressure is divided by the left ankle systolic blood pressure to get 0.81. This score is between 0.71 and 0.90, which suggests mild peripheral artery disease.Moderate peripheral artery disease would yield a score of 0.41 to 0.70. Severe peripheral artery dis- ease would result in a score of 0.00 to 0.40.
CN: Physiological adaptation;
CL: Analyze
101.
3. Keeping the involved extremity at or below the body’s horizontal plane will facilitate tissue per- fusion and prevent tissue damage. The nurse should avoid placing the affected extremity on a hard surface, such as a fi rm mattress, to avoid pressure ulcers. In addition, the involved extremity should be free from heavy overlying bed linens. The nurse should handle the involved extremity in a gentle fashion to prevent friction or pressure. Raising the leg would cause occlusion to the iliac artery, which is contrary to the goal to promote arterial circulation.CN: Physiological adaptation;
CL: Synthesize
93.
4. The client is experiencing paralytic ileus.One of the adverse effects of morphine used to man- age pain is decreased GI motility. Bowel manipula- tion and immobility also contribute to a postopera- tive ileus. Insertion of an NG tube generally prevents a postoperative ileus. The ice chips and I.V. fl uids will not affect the ileus.
CN: Basic care and comfort; CL: Analyze
94.
3. The client with a synthetic graft may need to be treated with prophylactic antibiotics before undergoing major dental work. This reduces the danger of systemic infection caused by bacteria from the oral cavity. Venous access for drawing blood, I.V.line insertion, and X-rays do not contribute to the risk of infection.
CN: Pharmacological and parenteral therapies; CL: Synthesize
95.
2. These symptoms suggest that the client is receiving too much Coumadin. Coumadin hin- ders the hepatic synthesis of vitamin K–dependent clotting factors and prolongs the clotting time.Because many factors infl uence the effectiveness of Coumadin, the dosage is monitored closely. Signs and symptoms of blood loss include bleeding gums, petechiae, bruises, dark stools, and dark urine.
CN: Pharmacological and parenteral therapies; CL: Evaluate
The Client with Stasis Ulcers
96.
1, 2, 4, 5. The underlying pathophysiology in stasis ulcers of the skin surface is a result of inad- equate oxygen and other nutrients to the tissues because of edema and decreased circulation. The nurse should fi rst initiate care that will increase oxygen and improve tissue integrity. It is also impor- tant to prevent trauma to the tissues and prevent infections, which result from decreased microcircu- lation that limits the body’s response to infection.Stasis ulcers are painful. The nurse can administer prescribed analgesics 30 minutes before changing the dressing. There is no indication that the client’s overall nutrition needs to be improved.
CN: Physiological adaptation; CL: Create
97.
1. The result of chronic venous stasis is swelling and edema and superfi cial varicose veins.Diuretics will help reduce the swelling, thus improv- ing capillary circulation. Although diuretics may decrease blood pressure, that is not the intended out- come of this drug. The nurse should teach the client to prevent infection and monitor wound healing, but these are not the primary outcomes of chlorothiazide.
CN: Pharmacological and parenteral therapies; CL: Evaluate
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