Chapter 38: Nursing Management: Vascular Disorders My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 38: Nursing Management: Vascular Disorders

Test Bank

MULTIPLE CHOICE

1. When discussing risk factor modification for a 60-year-old patient who has a 4-cm abdominal aortic aneurysm, the nurse will focus patient teaching on which of these patient risk factors?

a.

Male gender

b.

Marfan syndrome

c.

Abdominal trauma history

d.

Uncontrolled hypertension

ANS: D

All of the factors contribute to the patients risk, but only the hypertension can potentially be modified to decrease the patients risk for further expansion of the aneurysm.

DIF: Cognitive Level: Application REF: 867-869

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

2. A patient has a 5-cm thoracic aortic aneurysm that was discovered during a routine chest x-ray. When obtaining a nursing history from the patient, it will be most important to ask about

a.

back or lumbar pain.

b.

difficulty swallowing.

c.

abdominal tenderness.

d.

changes in bowel habits.

ANS: B

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.

DIF: Cognitive Level: Application REF: 868-869

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

3. Several hours after an open surgical repair of an abdominal aortic aneurysm, the patient develops a urinary output of 20 mL/hr for 2 hours. The nurse notifies the health care provider and anticipates orders for

a.

an additional antibiotic.

b.

a white blood cell (WBC) count.

c.

a decrease in IV infusion rate.

d.

a blood urea nitrogen (BUN) level.

ANS: D

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 patients decreased urinary output.

DIF: Cognitive Level: Application REF: 871-872 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

4. A patient in the outpatient clinic has a new diagnosis of peripheral artery disease (PAD). Which medication category will the nurse plan to include when providing patient teaching about PAD management?

a.

Statins

b.

Vitamins

c.

Thrombolytics

d.

Anticoagulants

ANS: A

Current research indicates that statin use by patients with PAD improves multiple outcomes. There is no research that supports the use of the other medication categories in PAD.

DIF: Cognitive Level: Application REF: 875-876 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

5. A patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. The nurse should notify the health care provider and

a.

elevate the left leg on a pillow.

b.

apply an elastic wrap to the leg.

c.

assist the patient in gently exercising the leg.

d.

keep the patient in bed in the supine position.

ANS: D

The patients history and clinical manifestations are consistent with acute arterial occlusion, and resting the leg will decrease the oxygen demand of the tissues and minimize ischemic damage until circulation can be restored. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the leg.

DIF: Cognitive Level: Application REF: 880-881

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

6. A patient at the clinic says, I have always taken an evening walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though. The nurse should

a.

attempt to palpate the dorsalis pedis and posterior tibial pulses.

b.

check for the presence of tortuous veins bilaterally on the legs.

c.

ask about any skin color changes that occur in response to cold.

d.

assess for unilateral swelling, redness, and tenderness of either leg.

ANS: A

The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynauds phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness point to venous thromboembolism (VTE).

DIF: Cognitive Level: Application REF: 878-879

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

7. The nurse performing an assessment with a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the left great toe would expect to find

a.

a positive Homans sign.

b.

swollen, dry, scaly ankles.

c.

prolonged capillary refill in all the toes.

d.

a large amount of drainage from the ulcer.

ANS: C

Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease.

DIF: Cognitive Level: Application REF: 874-875

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

8. In evaluating the patient outcomes following teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says,

a.

I will have to buy some loose clothing that does not bind across my legs or waist.

b.

I will use a heating pad on my feet at night to increase the circulation and warmth in my feet.

c.

I will walk to the point of pain, rest, and walk again until I develop pain for a half hour daily.

d.

I will change my position every hour and avoid long periods of sitting with my legs down.

ANS: B

Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. The other patient statements are correct and indicate that teaching has been successful.

DIF: Cognitive Level: Application REF: 876 | 878-880

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

9. After teaching a patient with newly diagnosed Raynauds phenomenon about how to manage the condition, which behavior by the patient indicates that the teaching has been effective?

a.

The patient avoids the use of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).

b.

The patient exercises indoors during the winter months.

c.

The patient places the hands in hot water when they turn pale.

d.

The patient takes pseudoephedrine (Sudafed) for cold symptoms.

ANS: B

Patients should avoid temperature extremes by exercising indoors when it is cold. To avoid burn injuries, the patient should use warm, rather than hot, water to warm the hands. Pseudoephedrine is a vasoconstrictor and should be avoided. There is no reason to avoid taking aspirin and NSAIDs with Raynauds phenomenon.

DIF: Cognitive Level: Application REF: 881-883 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

10. The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with deep vein thrombosis. The best method for the nurse to use in elevating the patients feet is to

a.

place the patient in the Trendelenburg position.

b.

place two pillows under the calf of the affected leg.

c.

elevate the bed at the knee and put pillows under the feet.

d.

put one pillow under the thighs and two pillows under the lower legs.

ANS: D

The purpose of elevating the feet is to enhance venous flow from the feet to the right atrium, which is best accomplished by placing two pillows under the feet and one under the thighs. 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.

DIF: Cognitive Level: Application REF: 889-890

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

11. The health care provider prescribes an infusion of argatroban (Acova) and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). The nurse will plan to

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.

ANS: A

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.

DIF: Cognitive Level: Application REF: 887 | 889-890

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

12. A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is accurate?

a.

Administration of two anticoagulants reduces the risk for recurrent venous thrombosis.

b.

Lovenox will start to dissolve the clot, and Coumadin will prevent any more clots from occurring.

c.

The Lovenox will work immediately, but the Coumadin takes several days to have an effect on coagulation.

d.

Because of the potential for a pulmonary embolism, it is important for you to have more than one anticoagulant.

ANS: C

Low molecular weight heparin (LMWH) is used because of the immediate effect on coagulation and discontinued once the international normalized ratio (INR) value indicates that the warfarin has reached a therapeutic level. LMWH has no thrombolytic properties. The use of two anticoagulants is not related to the risk for pulmonary embolism, and two are not necessary to reduce the risk for another VTE.

DIF: Cognitive Level: Application REF: 885-888

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

13. The nurse has initiated discharge teaching for a patient who is to be maintained on warfarin (Coumadin) following hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says,

a.

I should reduce the amount of green, leafy vegetables that I eat.

b.

I should wear a Medic Alert bracelet stating that I take Coumadin.

c.

I will need to have blood tests routinely to monitor the effects of the Coumadin.

d.

I will check with my health care provider before I begin or stop any medication.

ANS: A

Patients taking Coumadin are taught to follow a consistent diet with regard to foods that are high in vitamin K, such as green, leafy vegetables. The other patient statements are accurate.

DIF: Cognitive Level: Application REF: 890-891 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

14. A 42-year-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Before discharging the patient, the nurse teaches the patient that

a.

sitting at the work counter, rather than standing, is recommended.

b.

compression stockings should be applied before getting out of bed.

c.

exercises such as walking or jogging cause recurrence of varicosities.

d.

taking one aspirin daily will help prevent clotting around venous valves.

ANS: B

Compression stockings are applied with the legs elevated to reduce pressure in the lower legs. Walking is recommended to prevent recurrent varicosities. Sitting and standing are both risk factors for varicose veins and venous insufficiency. An aspirin a day is not adequate to prevent venous thrombosis and would not be recommended to the patient who had just had sclerotherapy.

DIF: Cognitive Level: Application REF: 891-892

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

15. Which topic will the nurse include in patient teaching for a patient with a venous stasis ulcer on the right lower leg?

a.

Adequate carbohydrate intake

b.

Prophylactic antibiotic therapy

c.

Application of compression to the leg

d.

Methods of keeping the wound area dry

ANS: C

Compression of the leg is essential to healing of venous stasis ulcers. 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.

DIF: Cognitive Level: Application REF: 892-893 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

16. A patient is admitted to the hospital with a diagnosis of chronic venous insufficiency. Which of these statements by the patient is most consistent with the diagnosis?

a.

I cant 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.

ANS: A

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).

DIF: Cognitive Level: Application REF: 892-893

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

17. Which nursing action will be included in the plan of care after endovascular repair of an abdominal aortic aneurysm?

a.

Record hourly chest tube drainage.

b.

Monitor fluid intake and urine output.

c.

Check the abdominal wound for redness or swelling.

d.

Teach the reason for a prolonged rehabilitation process.

ANS: B

Because renal artery occlusion can occur after endovascular repair, the nurse should monitor parameters of renal function such as intake and output. Chest tubes will not be needed for endovascular surgery, the recovery period will be short, and there will not be an abdominal wound.

DIF: Cognitive Level: Application REF: 869-870 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

18. Which action by a nurse who is administering fondaparinux (Arixtra) 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 Arixtra.

ANS: D

The air bubble is not ejected before giving Arixtra. The other actions by the nurse are appropriate.

DIF: Cognitive Level: Application REF: 886

TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment

19. A patient tells the health care provider about experiencing cold, numb fingers when running during the winter and is diagnosed with Raynauds phenomenon. The nurse will anticipate teaching the patient about tests for

a.

hypertension.

b.

hyperlipidemia.

c.

autoimmune disorders.

d.

coronary artery disease.

ANS: C

Secondary Raynauds phenomenon may occur in conjunction with autoimmune diseases such as rheumatoid arthritis, and patients should be screened for autoimmune disorders. Raynauds phenomenon is not associated with hyperlipidemia, hypertension, or coronary artery disease.

DIF: Cognitive Level: Application REF: 881-882 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

20. While working in the outpatient clinic, the nurse notes that the medical record states that a patient has intermittent claudication. Which of these statements by the patient would be 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.

ANS: D

Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication. Finger pain associated with cold weather is typical of Raynauds 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.

DIF: Cognitive Level: Application REF: 874

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

21. When developing a teaching plan for a patient newly diagnosed with peripheral artery disease (PAD), which information should the nurse include?

a.

Exercise only if you do not experience any pain.

b.

It is very important that you stop smoking cigarettes.

c.

Try to keep your legs elevated whenever you are sitting.

d.

Put on support hose early in the day before swelling occurs.

ANS: B

Smoking cessation is essential for slowing the progression of PAD to critical limb ischemia and reducing the risk of myocardial infarction and death. Circulation to the legs will decrease if the legs are elevated. Patients with PAD are taught to exercise to the point of feeling pain, rest, and then resume walking. Support hose are not used for patients with PAD.

DIF: Cognitive Level: Application REF: 875-876 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

22. A patient with a history of an abdominal aortic aneurysm is admitted to the emergency department (ED) with severe back pain and absent pedal pulses. Which action should the nurse take first?

a.

Obtain the blood pressure.

b.

Ask the patient about tobacco use.

c.

Draw blood for ordered laboratory testing.

d.

Assess for the presence of an abdominal bruit.

ANS: A

Since the patient appears to be experiencing aortic dissection, the nurses first action should be to determine the hemodynamic status by assessing blood pressure. The other actions also may be done, but they will not provide information that will determine what interventions are needed immediately for this patient.

DIF: Cognitive Level: Application REF: 868-869

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

23. Which of these patients admitted to the emergency department should the nurse assess first?

a.

62-year-old who has gangrenous ulcers on both feet

b.

50-year-old who is complaining of tearing chest pain

c.

45-year-old who is taking anticoagulants and has bloody stools

d.

36-year-old who has right calf tenderness, redness, and swelling

ANS: B

The patients presentation is consistent with dissecting thoracic aneurysm, which will require rapid intervention. The other patients do not need urgent interventions.

DIF: Cognitive Level: Analysis REF: 871-872

OBJ: Special Questions: Multiple Patients

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

24. 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 action should the nurse take first?

a.

Wrap both the legs in warm blankets.

b.

Notify the surgeon and anesthesiologist.

c.

Document that the pulses are absent and recheck in 30 minutes.

d.

Review the preoperative assessment form for data about the pulses.

ANS: D

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 patients 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 patients legs.

DIF: Cognitive Level: Application REF: 871

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

25. When the nurse is caring for a patient on the first postoperative day after an abdominal aortic aneurysm repair, which assessment finding 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

ANS: B

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.

DIF: Cognitive Level: Application REF: 871

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

26. When caring for a patient with critical limb ischemia who has just arrived on the nursing unit after having percutaneous transluminal balloon angioplasty, which action should the nurse take first?

a.

Take the blood pressure and pulse rate.

b.

Check for the presence of pedal pulses.

c.

Assess the appearance of any ischemic ulcers.

d.

Start discharge teaching about antiplatelet drugs.

ANS: A

Bleeding is a possible complication after catheterization of the femoral artery, so the nurses first action should be to assess for changes in vital signs that might indicate hemorrhage. The other actions also are appropriate but can be done after determining that bleeding is not occurring.

DIF: Cognitive Level: Application REF: 876-877

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

27. A patient who has had a femoral-popliteal bypass graft to the right leg is being cared for on the surgical unit. Which action by an LPN/LVN caring for the patient requires the RN to intervene?

a.

The LPN/LVN places the patient in a Fowlers position for meals.

b.

The LPN/LVN has the patient sit in a bedside chair for 90 minutes.

c.

The LPN/LVN assists the patient to ambulate 40 feet in the hallway.

d.

The LPN/LVN administers the ordered aspirin 160 mg after breakfast.

ANS: B

The patient should avoid sitting for long periods because of the increased stress on the suture line caused by leg edema and because of the risk for venous thromboembolism (VTE). The other actions by the LPN/LVN are appropriate.

DIF: Cognitive Level: Application REF: 878-879

OBJ: Special Questions: Delegation TOP: Nursing Process: Implementation

MSC: NCLEX: Safe and Effective Care Environment

28. A 46-year-old is diagnosed with thromboangiitis obliterans (Buergers disease). When the nurse is planning expected outcomes for the patient, which outcome 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

ANS: A

Absolute cessation of nicotine use is needed to reduce the risk for amputation in patients with Buergers disease. Other therapies have limited success in treatment of this disease.

DIF: Cognitive Level: Application REF: 881

OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

29. Which information about a patient who has been admitted with a right calf venous thromboembolism (VTE) requires immediate action by the nurse?

a.

Complaint of left calf pain

b.

New onset shortness of breath

c.

Red skin color of left lower leg

d.

Temperature of 100.4 F (38 C)

ANS: B

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.

DIF: Cognitive Level: Application REF: 888-889

OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

30. Which nursing action in the care plan for a patient who had an open repair of an abdominal aortic aneurysm 3 days previously is appropriate for the nurse to delegate to experienced nursing assistive personnel (NAP)?

a.

Check the lower extremity strength and movement.

b.

Monitor the quality and presence of the pedal pulses.

c.

Teach the patient the signs of possible wound infection.

d.

Help the patient to use a pillow to splint while coughing.

ANS: D

Assisting a patient who has already been taught how to cough is part of routine postoperative care and within the education and scope of practice for an experienced NAP. Patient teaching and assessment of essential postoperative functions such as circulation and movement should be done by RNs.

DIF: Cognitive Level: Application REF: 870-871 | Surgical Repair of the Aorta on Evolve

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

COMPLETION

1. When assessing a patient with possible peripheral artery disease (PAD), the nurse obtains a brachial BP of 140/80 and an ankle pressure of 110/70. The nurse calculates the patients ankle-brachial index (ABI) as ____________________.

ANS:

0.78 or 0.79

The ABI is calculated by dividing the ankle systolic BP by the brachial systolic BP.

DIF: Cognitive Level: Application REF: 874-875

OBJ: Special Questions: Alternate Item Format

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

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