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
While assessing a patient the nurse notes that the patients ankle-brachial index (ABI) of the right leg is 0.40 . How should the nurse best respond to this assessment finding?
Correct Answer: B
Rationale: ABI is used to assess the degree of stenosis of peripheral arteries. An ABI of less than 1.0 indicates possible claudication of the peripheral arteries. It does not indicate inadequate coronary output. There is no direct indication for changes in vitamin K intake and OTC medications are not likely causative.
Question 2 of 5
The nurse is providing care for a patient who has just been diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis?
Correct Answer: B
Rationale: PAD assessment may manifest as unequal pulses between extremities, with the affected leg cooler and paler than the unaffected leg. Intermittent claudication is far more common than sensations of numbness and tingling. Clubbing and muscle atrophy are not associated with PAD.
Question 3 of 5
The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during the admission assessment that the patient takes oral contraceptives. Consequently, the nurses postoperative plan of care should include what intervention?
Correct Answer: A
Rationale: Oral contraceptive use increases blood coagulability; with bed rest, the patient may be at increased risk of developing deep vein thrombosis. Leg exercises and early ambulation are among the interventions that address this risk. Assessment of peripheral circulation is important, but Doppler ultrasound may not be necessary to obtain these data. Dependent positioning increases the risk of venous thromboembolism (VTE). Contraceptives are not normally discontinued to address the risk of VTE in the short term.
Question 4 of 5
A nurse is creating an education plan for a patient with venous insufficiency. What measure should the nurse include in the plan?
Correct Answer: A
Rationale: Measures taken to prevent complications include avoiding tight-fitting socks and panty girdles; maintaining activities, such as walking, sleeping with legs elevated, and using pressure stockings. Not included in the teaching plan for venous insufficiency would be reducing activity, sleeping with legs dependent, and avoiding pressure stockings. Each of these actions exacerbates venous insufficiency.
Question 5 of 5
The nurse is caring for a patient with a large venous leg ulcer. What intervention should the nurse implement to promote healing and prevent infection?
Correct Answer: A
Rationale: Wound healing is highly dependent on adequate nutrition. The diet should be sufficiently high in calories and protein. Antibiotic ointments are not normally used on the skin surrounding a leg ulcer and occlusive dressings can exacerbate impaired blood flow. Hydrogen peroxide is not normally used because it can damage granulation tissue.