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
How should the nurse best position a patient who has leg ulcers that are venous in origin?
Correct Answer: C
Rationale: Positioning of the legs depends on whether the ulcer is of arterial or venous origin. With venous insufficiency, dependent edema can be avoided by elevating the lower extremities. Dangling the patients legs and applying pillows may further compromise venous return.
Question 2 of 5
A patient with advanced venous insufficiency is confined following orthopedic surgery. How can the nurse best prevent skin breakdown in the patients lower extremities?
Correct Answer: A
Rationale: If the patient is on bed rest, it is important to relieve pressure on the heels to prevent pressure ulcerations, since the heels are among the most vulnerable body regions. Monitoring blood work does not directly prevent skin breakdown, even though albumin is related to wound healing. Massage is not normally indicated and may exacerbate skin breakdown. Passive range-of-motion exercises do not directly reduce the risk of skin breakdown.
Question 3 of 5
The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers. The nurses assessment should include which of the following components?
Correct Answer: A,C,D,E
Rationale: A careful nursing history and assessment are important. The extent and type of pain are carefully assessed, as are the appearance and temperature of the skin of both legs. The quality of all peripheral pulses is assessed, and the pulses in both legs are compared. Any limitation of mobility and activity that results from vascular insufficiency is identified. Not likely is there any direct indication for assessment of apical heart rate, although peripheral pulses must be assessed.
Question 4 of 5
A nurse on a medical unit is caring for a patient who has been diagnosed with lymphangitis. When reviewing this patients medication administration record, the nurse should anticipate which of the following?
Correct Answer: C
Rationale: Lymphangitis is an acute inflammation of the lymphatic channels caused by an infectious process. Antibiotics are always a component of treatment. Diuretics are of nominal use. Anticoagulants and antiplatelet aggregators are not indicated in this form of infection.
Question 5 of 5
A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the patients left leg is visibly swollen and reddened. What is the nurses most appropriate action?
Correct Answer: B
Rationale: VTE requires prompt medical follow-up. Heparin will not dissolve an established clot. Massaging the patients leg and mobilizing the patient would be contraindicated because they would dislodge the clot, possibly resulting in a pulmonary embolism.