ATI LPN
Lewis's Medical Surgical Nursing in Canada, 5th Edition
Chapter 40 Questions
Question 1 of 5
While working in the outpatient clinic, the nurse notes that the medical record states that a patient has intermittent claudication. Which of the following patient statements is consistent with this information?
Correct Answer: D
Rationale: Cramping that is precipitated by a consistent level of exercise is descriptive of intermittent claudication. Finger pain associated with cold weather is typical of Raynaud's phenomenon. Fatigue that occurs sometimes with exercise is not typical of intermittent claudication, which is reproducible. Swelling associated with prolonged standing is typical of venous disease.
Question 2 of 5
The nurse is assessing a patient in the emergency department with a history of an abdominal aortic aneurysm with severe back pain and absent pedal pulses. Which of the following actions should the nurse take first?
Correct Answer: A
Rationale: Since the patient appears to be experiencing aortic dissection, the nurse's first action should be to determine the hemodynamic status by assessing blood pressure. The other actions also may be done, but they will not provide information that will determine what interventions are needed immediately for this patient.
Question 3 of 5
Which of the following nursing actions should be included in the plan of care for a patient who has had endovascular repair of an abdominal aortic aneurysm?
Correct Answer: B
Rationale: Because renal artery occlusion can occur after endovascular repair, the nurse should monitor parameters of renal function such as intake and output. Chest tubes will not be needed for endovascular surgery, the recovery period will be short, and there will not be an abdominal wound.
Question 4 of 5
The nurse is caring for a patient with chronic atrial fibrillation who develops sudden severe pain, pulselessness, pallor, and coolness in the left leg. Which of the following actions should the nurse implement first?
Correct Answer: D
Rationale: The patient's history and clinical manifestations are consistent with acute arterial occlusion. Clinical manifestations of acute arterial ischemia include the 'six Ps': pain, pallor, paralysis, pulselessness, paresthesia, and poikilothermia (adaptation of the limb to the environmental temperature most often cool). Without immediate intervention, ischemia may progress quickly to tissue necrosis and gangrene within a few hours. If the nurse detects these signs, the nurse should immediately notify the health care provider. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the leg.
Question 5 of 5
The nurse is providing teaching to a patient with a venous ulcer on the right lower leg. Which of the following patient statements indicates a need for further teaching?
Correct Answer: B
Rationale: Compression of the leg is essential to healing of venous ulcers in patients with chronic venous insufficiency. High dietary intake of protein, rather than carbohydrates, is needed. Prophylactic antibiotics are not routinely used for venous ulcers. Moist environment dressings are used to hasten wound healing. Applying a compression dressing only in the evening is insufficient; it should be worn consistently to promote healing.