PT 2

55問 • 1年前

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Which postoperative sign should a nurse report immediately when caring for a patient with an endarterectomy with a synthetic graft?

fever

A patient with Raynaud disease haspoor tissue perfusion and is being givendischarge instructions. Which instructionshould the nurse include when providingthis information?

Wear gloves and warm socks when outdoors.

Which assessment should a nurse perform on a patient after the repair of anabdominal aortic aneurysm?

Bowel sounds

Which patient teaching should be included for a patient with varicose veins?

weight reductions

The nurse is caring for a patient diagnosed with arterial embolism. Which patient teaching information will the nurse anticipate providing to the patient? (Select all that apply.)

Protect affected limbs from pressure., Gradually increase activity as tolerated., Raynaud phenomena

Hyperbaric O2 therapy may be prescribed in an attempt to promote healingof the ulcer by reducing capillary pressure and ______the blood.

hyperoxygenating

What is a normal age-related change inolder adults that makes them susceptibleto cardiovascular disease?

Stiff peripheral vessels

What should a nurse ask a patient related to past history of deep-vein thrombosis (DVT) and other vascular problems?

Recurring chest pain

A 69-year-old patient reports a burning,aching pain in the legs when walkingto the mailbox. These symptoms are relieved with rest. What should the nursesuspect?

claudication

A nurse records the assessment of stasis dermatitis on an intake assessmentfor a patient with peripheral vascular disease (PVD). What is the best way to describe this finding?

Brownish skin discoloration on the lower legs

A nurse assesses a patient's capillary refill time as less than 3 seconds. What does this assessment indicate?

Tissue perfusion

A nurse performs Homans maneuver byflexing the knee and sharply dorsiflexingthe foot. What response indicates a positive Homans sign?

Pain in the calf area

Which technique should the nurse implement when performing the Allen test on a patient to evaluate the adequacy ofcirculation in the radial artery?

Observes whether the color is returningto the hand, which indicates perfusion

A nurse records that a patient has a 3+edema to the right foot. How deep did thenurse's thumb depress the edematousarea?

To 1 inch

A nurse notes ulcerations on the surfaces of a patient's toes. What should thisassessment most likely indicate?

Arterial stasi

What is a characteristic of a venous stasis ulcer?

Painlessness

A nurse is caring for a patient whohas had an angiogram. What should thenurse make a point of care to assess anddocument on this patient?

Peripheral pulses in the affected leg

A nurse is educating a patient regarding a stress test on a treadmill. Teachingincludes that this test is a noninvasiveprocedure. What additional informationis appropriate for the nurse to include?

Is monitored continuously by blood pressure and an electrocardiogram

A patient inquires how something as simple as walking could help his venous vascular disorder. What is the best responseby the nurse when explaining the benefits of walking?

Boosts venous circulation through legmuscle activity

What is contraindicated for a patient performing Buerger-Allen exercises?

lying on stomach

A nurse cautions a patient with peripheral vascular disease (PVD) that continuedsmokingcauses detrimental vasoconstriction forup to

1 hour

A nurse is performing an intake examination on a patient with peripheral vasculardisease (PVD). Which lifestyle information identified by the patient aggravatesvascular disease?

Being employed as an air traffic controller

Vascular disease disorders often requirethe use of elastic stockings. Which actionshould the nurse implement when caringfor a patient with elastic stockings?

Remove the stockings for skin inspectiontwo times a day.

Which instruction is most appropriate fora patient with arterial insufficiency?

Frequently allow the legs to dangle dependently.

A nurse is preparing to administerlow-molecular-weight heparin (LMWH).What is a major advantage related to theadministration of LMWH?

It is provided fixed doses.

Which statement made by a patient indicates to the nurse that a teaching planfor the use of warfarin was not effective?

"I'm drinking too much tea. My urinelooks like tea."

A patient has returned from a vein ligation and stripping. What are the appropriate instructions for a nurse to provide?

Wear compression stockings to promotecirculation.

What medication obtained in a patient'shistory will lessen the effects of warfarin(Coumadin)

Yaz (drospirenone/estradiol) as an oralcontraceptive

An obese postsurgical patient complainsof sudden discomfort in her leg. Thenurse assesses the leg and finds it coldand pale with no pedal or popliteal pulse.What should the nurse suspect?

arterial occlusion

A patient with Raynaud disease has anursing diagnosis of "Ineffective tissueperfusion, related to vasoconstriction"and is being given discharge instructions. What should the nurse includewhen providing this information?

Wear gloves and warm socks when outdoors.

What assessment should a nurse perform on a patient after the repair of anabdominal aortic aneurysm?

bowel sounds

What patient teaching should be included for a patient with varicose veins?

weight reduction

Why do older persons adapt more slowly to changes in the peripheral vascularsystem? (Select all that apply.)

Slowing heart rate, Decreasing cardiac output, Thickening of aorta, Stiffening of blood vessels

A nurse suspects a circulatory disorderin one leg. Which assessments shouldthe nurse include when comparing bothlegs? (Select all that apply.)

Color, Hair loss on extremity, Pulse quality, Warmth

A nurse explains that the lining of a vessel that allows for smooth blood flow andalso reduced resistance in the vessel is ___________ the of the vessel.

intima

A nurse explains that when a patient history reveals a recent episode of vomitingand diarrhea, the nurse anticipates thatthis fluid loss will cause and increased ____________ blood viscosity

hemoconcentration

A student nurse is assessing the peripheral vascular system of an older adult.What action by the student would causethe faculty member to intervene?

Palpating both carotid arteries at the same time

The nurse is reviewing the lipid panel ofa male client who has atherosclerosis.Which finding is most concerning?

Triglycerides: 198 mg/dL

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet?

Baked chicken breast, broccoli, tomatoes

A nurse is working with a client who takesatorvastatin (Lipitor). The clients recentlaboratory results include a blood ureanitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by thenurse is best?

Ask if the client eats grapefruit.

A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack ofsymptoms. What response by the nurseis best?

"Most people with hypertension do nothave symptoms."

A student nurse asks what essential hypertension is. What response by the registered nurse is best?

"It is hypertension with no specific cause."

A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audienceshould the nurse provide this service?

African-American churches

A client has hypertension and high riskfactors for cardiovascular disease. Theclient is overwhelmed with the recommended lifestyle changes. What actionby the nurse is best?

Assist in finding one change the client can control.

The nurse is caring for four hypertensiveclients. Which druglaboratory value combination should the nurse report immediately to the health care provider?

Furosemide (Lasix)/potassium: 2.1mEq/L

A nurse is assessing a client with peripheral artery disease (PAD). The clientstates walking five blocks is possiblewithout pain. What question asked nextby the nurse will give the best information?

"Could you walk further than that a few months ago?"

An older client with peripheral vasculardisease (PVD) is explaining the daily footcare regimen to the family practice clinicnurse. What statement by the client mayindicate a barrier to proper foot care?

"My hands shake when I try to do thingsrequiring coordination."

A client is taking warfarin (Coumadin)and asks the nurse if taking St. Johnswort is acceptable. What response by thenurse is best?

"No, it may interfere with the warfarin."

A nurse is teaching a larger female clientabout alcohol intake and how it affectshypertension. The client asks if drinkingtwo beers a night is an acceptable intake.What answer by the nurse is best?

"No, women should only have one beer a day as a general rule."

A nurse is caring for four clients. Whichone should the nurse see first?

Client who had a first dose of captopril(Capoten) and needs to use the bathroom

A client had a percutaneous transluminalcoronary angioplasty for peripheral arterial disease. What assessment finding bythe nurse indicates a priority outcome forthis client has been met?

Distal pulse on affected extremity 2+/4+

A client is 4 hours postoperative aftera femoropopliteal bypass. The client reports throbbing leg pain on the affectedside, rated as 7/10. What action by thenurse takes priority

Assess distal pulses and skin color.

A client had a femoropopliteal bypassgraft with a synthetic graft. What actionby the nurse is most important to preventwound infection?

Appropriate hand hygiene before giving care

A client is receiving an infusion of alteplase (Activase) for an intra-arterialclot. The client begins to mumble andis disoriented. What action by the nursetakes priority?

Notify the Rapid Response Team.

A nursing student is caring for a clientwith an abdominal aneurysm. What action by the student requires the registered nurse to intervene?

Palpates the abdomen in four quadrants

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