ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 30 : Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation Questions
Question 1 of 5
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?
Correct Answer: D
Rationale: 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.
Question 2 of 5
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?
Correct Answer: B,C,D
Rationale: 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.
Question 3 of 5
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?
Correct Answer: C
Rationale: 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.
Question 4 of 5
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?
Correct Answer: D
Rationale: Pregnancy may cause varicosities because of hormonal effects related to decreased venous outflow, 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.
Question 5 of 5
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?
Correct Answer: D
Rationale: 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.