PT 3

39問 • 1年前

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A nurse is caring for a client with a deepvein thrombosis (DVT). What nursing assessment indicates a priority outcomehas been met?

Oxygen saturation of 98%

A client has a deep vein thrombosis(DVT). What comfort measure does thenurse delegate to the unlicensed assistive personnel (UAP)

Apply a warm moist pack.

A nurse is assessing an obese client inthe clinic for follow-up after an episodeof deep vein thrombosis. The client haslost 20 pounds since the last visit. Whataction by the nurse is best?

Measure for new compression stockings.

A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal?

Participate in blood pressure screeningsat the mall

A client has been diagnosed with a deepvein thrombosis and is to be dischargedon warfarin (Coumadin). The client is adamant about refusing the drug because its dangerous. What action by the nurse is best?

Assess the reason behind the client's fear.

A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril(Prinivil) and warfarin (Coumadin). Theclient reports new-onset cough. What action by the nurse is most appropriate?

Assess the client's lung sounds andoxygenation.

A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best?

Consult with the Wound Ostomy Care Nurse.

A client has peripheral arterial disease(PAD). What statement by the client indicates misunderstanding about self-management activities?

"I can use a heating pad on my legs if it's set on low."

A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse?

Ensure the client has a patent airway.

The nurse is assessing a client on admission to the hospital. The clients leg appears as shown below:

Assess the client's ankle-brachial index.

What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.)

Applying elastic compression stockings, Elevating the legs when sitting or lying, Reminding the client to do leg exercises

A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Raising the siderails on the bed., Recording baseline vital signs.

A client has been bedridden for several days after major abdominal surgery.What action does the nurse delegateto the unlicensed assistive personnel(UAP) for deep vein thrombosis (DVT)prevention? (Select all that apply.)

Apply compression stockings., Assist with ambulation., Offer fluids frequently.

A nurse is caring for a client on IV infusion of heparin. What actions does thisnurse include in the clients plan of care?(Select all that apply.)

Assess the client for bleeding., Monitor the daily activated partial thromboplastin time (aPTT) results., Use an IV pump for the infusion.

A client is being discharged on warfarin(Coumadin) therapy. What discharge instructions is the nurse required to provide? (Select all that apply.)

Dietary restrictions, Follow-up laboratory monitoring, Possible drug-drug interactions, Reason to take medication

Which statements by the client indicategood understanding of foot care in peripheral vascular disease? (Select allthat apply.)

"I will keep my feet dry, especially between the toes.", "Lotion is important to keep my feetsmooth and soft.", "Washing my feet in room-temperaturewater is best."

A nurse is caring for a client with a nonhealing arterial ulcer. The physician hasinformed the client about possibly needing to amputate the clients leg. The clientis crying and upset. What actions by thenurse are best? (Select all that apply.)

Ask the client to describe his or her current emotions., Assess the client for support systemsand family., Offer to stay with the client if he or shedesires.

The nurse working in the emergency department knows that which factors arecommonly related to

Atherosclerosis, History of hypertension, History of smoking

A client with a known abdominal aorticaneurysm reports dizziness and severeabdominal pain. The nurse assesses theclients blood pressure at 82/40 mm Hg.What actions by the nurse are most important? (Select all that apply.)

Assess distal pulses every 10 minutes., Notify the Rapid Response Team., Take vital signs every 10 minutes.

A nurse explains that the lining of a vessel that allows for smooth blood flow andalso reduced resistance in the vessel isthe_____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 patient with Raynaud disease haspoor tissue perfusion and is being givendischarge instructions. What should the nurse include when providing this information?

Wear gloves and warm socks when outdoors.

Hyperbaric O2 therapy may be prescribed in an attempt to promote healing of the ulcer by reducing capillary pressure and______the blood

hyperoxygenating

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 has a deep vein thrombosis(DVT). What comfort measure does thenurse delegate to the unlicensed assistive personnel (UAP)?

Apply a warm moist pack.

A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is bes

Consult with the Wound Ostomy Care Nurse.

Apply compression stockings., Offer fluids frequently., Assist with ambulation.

Several hours after a patient had an opensurgical repair of an abdominal aorticaneurysm, the UAP reports to the nursethat urinary output for the past 2 hourshas been 45 mL. The nurse notifies the health care provider and anticipates anorder for a(n)

increased IV infusion rate.

The health care provider prescribes aninfusion of heparin and daily partialthromboplastin time (PTT) testing for apatient with venous thromboembolism(VTE). The nurse will plan to

Avoid giving IM medications to prevent localized bleeding.

The nurse is caring for a patient with adescending aortic dissection. Which assessment finding is most important toreport to the health care provider?

Blood pressure of 138/88 mm Hg

what is arterial pain like;

sharp worst at night, activity causes severe pain in calf muscles, thigh, butt, rest pain b/c leg elevated

what is venous pain like

heavy, dull, throbbing, achy, worst when standing/sitting for long periods

Arterial skin systems

cool to touch, thin, dry/ scaly skin, hairless, thick toenails

Arterial DR EP mean?

Dange legs= Rubor, Elevate legs - Pale

Venous skin system ?

warm to touch, thick/ tough skin, brownish color

Arterial Pulse ?

Very poor or absent

Dx Arterial pulse by using a

doppler device

When auscultating over the patient's abdominal aorta, the nurse hears a loudhumming sound. The nurse documentsthis finding as a

bruit

A nurse cautions a patient with peripheral vascular disease (PVD) that continued smoking causes detrimental vasoconstriction for up to ___\after only onecigarette.

1 hr

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