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Lewis: Chapter 37: Vascular Disorders

Terms in this set (31)

A nurse is caring for a patient with a diagnosis of deep venous thrombosis (DVT). The patient has an order to receive 30 mg enoxaparin (Lovenox). Which injection site should the nurse use to administer this medication safely?

A. Buttock, upper outer quadrant
B. Abdomen, anterior-lateral aspect
C. Back of the arm, 2 inches away from a mole
D. Anterolateral thigh, with no scar tissue nearby
B. Abdomen, anterior-lateral aspect
Enoxaparin (Lovenox) is a low-molecular-weight (LMW) heparin that is given as a deep subcutaneous injection in the right and left anterolateral abdomen. All subcutaneous injections should be given away from scars, lesions, or moles.
The nurse is preparing to administer a scheduled dose of enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to administer this medication correctly?

A. Remove the air bubble in the prefilled syringe.
B. Aspirate before injection to prevent IV administration.
C. Rub the injection site after administration to enhance absorption.
D. Pinch the skin between the thumb and forefinger before inserting the needle.
D. Pinch the skin between the thumb and forefinger before inserting the needle.
The nurse should gather together or "bunch up" the skin between the thumb and the forefinger before inserting the needle into the subcutaneous tissue. The nurse should not remove the air bubble in the prefilled syringe, aspirate, nor rub the site after injection.
The nurse is admitting a 68-year-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication?

A. Vitamin K
B. Cobalamin
C. Heparin sodium
D. Protamine sulfate
A. Vitamin K
Coumadin is a Vitamin K antagonist anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin (Coumadin).
The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed?

A. Decreased cardiac output
B. Increased blood pressure
C. Cerebral or pulmonary emboli
D. Excessive bleeding from incision or IV sites
C. Cerebral or pulmonary emboli
Warfarin is an anticoagulant that is used to prevent thrombi from forming on the walls of the atria during atrial fibrillation. Once the medication is terminated, thrombi could again form. If one or more thrombi detach from the atrial wall, they could travel as cerebral emboli from the left atrium or pulmonary emboli from the right atrium.
The nurse is reviewing the laboratory test results for a 68-year-old patient whose warfarin (Coumadin) therapy was terminated during the preoperative period. The nurse concludes that the patient is in the most stable condition for surgery after noting which INR (international normalized ratio) result?

A. 1.0
B. 1.8
C. 2.7
D. 3.4
A. 1.0
The therapeutic range for INR is 2.0 to 3.0 for many clinical diagnoses. The larger the INR number, the greater the amount of anticoagulation. For this reason, the safest value before surgery is 1.0, meaning that the anticoagulation has been reversed.
The nurse would determine that a postoperative patient is not receiving the beneficial effects of enoxaparin (Lovenox) after noting what during a routine shift assessment?

A. Generalized weakness and fatigue
B. Crackles bilaterally in the lung bases
C. Pain and swelling in lower extremity
D. Abdominal pain with decreased bowel sounds
C. Pain and swelling in lower extremity
Enoxaparin is a low-molecular-weight heparin used to prevent the development of deep vein thromboses (DVTs) in the postoperative period. Pain and swelling in the lower extremity can indicate development of DVT and therefore may signal ineffective medication therapy.
A postoperative patient asks the nurse why the physician ordered daily administration of enoxaparin (Lovenox). Which reply by the nurse is most appropriate?

A. "This medication will help prevent breathing problems after surgery, such as pneumonia."
B. "This medication will help lower your blood pressure to a safer level, which is very important after surgery."
C. "This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal."
D. "This medication is a narcotic pain medication that will help take away any muscle aches caused by positioning on the operating room table."
C. "This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal."
Enoxaparin is an anticoagulant that is used to prevent DVTs postoperatively. All other explanations/options do not describe the action/purpose of enoxaparin.
The nurse is caring for a preoperative patient who has an order for vitamin K by subcutaneous injection. The nurse should verify that which laboratory study is abnormal before administering the dose?

A. Hematocrit (Hct)
B. Hemoglobin (Hgb)
C. Prothrombin time (PT)
D. Partial thromboplastin time (PTT)
C. Prothrombin time (PT)
Vitamin K counteracts hypoprothrombinemia and/or reverses the effects of warfarin (Coumadin) and thus decreases the risk of bleeding. High values for either the prothrombin time (PT) or the international normalized ratio (INR) demonstrates the need for this medication.
The nurse is caring for a newly admitted patient with vascular insufficiency. The patient has a new order for enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to correctly administer this medication?

A. Spread the skin before inserting the needle.
B. Leave the air bubble in the prefilled syringe.
C. Use the back of the arm as the preferred site.
D. Sit the patient at a 30-degree angle before administration.
B. Leave the air bubble in the prefilled syringe.
The nurse should not expel the air bubble from the prefilled syringe because it should be injected to clear the needle of medication and avoid leaving medication in the needle track in the tissue.
A patient with varicose veins has been prescribed compression stockings. How should the nurse teach the patient to use these?

A. "Try to keep your stockings on 24 hours a day, as much as possible."
B. "While you're still lying in bed in the morning, put on your stockings."
C. "Dangle your feet at your bedside for 5 minutes before putting on your stockings."
D. "Your stockings will be most effective if you can remove them for a few minutes several times a day."
B. "While you're still lying in bed in the morning, put on your stockings."
The patient with varicose veins should apply stockings in bed, before rising in the morning. Stockings should not be worn continuously, but they should not be removed several times daily. Dangling at the bedside prior to application is likely to decrease their effectiveness.
Assessment of a patient's peripheral IV site reveals that phlebitis has developed over the past several hours. Which intervention should the nurse implement first?

A. Remove the patient's IV catheter.
B. Apply an ice pack to the affected area.
C. Decrease the IV rate to 20 to 30 mL/hr.
D. Administer prophylactic anticoagulants.
A. Remove the patient's IV catheter.
A 62-year-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral artery disease (PAD). The patient is a smoker and has a history of gout. What should the nurse focus her teaching on to prevent complications for this patient?

A. Gender
B. Smoking
C. Ethnicity
D. Co-morbidities
B. Smoking
Smoking is the most significant factor for this patient. PAD is a marker of advanced systemic atherosclerosis. Therefore tobacco cessation is essential to reduce PAD progression, CVD events, and mortality. Diabetes mellitus and hyperuricemia are also risk factors. Being male or Hispanic are not risk factors for PAD.
What medications should the nurse expect to include in the teaching plan to decrease the risk of cardiovascular events and death for PAD patients (select all that apply)?

A. Ramipril (Altace)
B. Cilostazol (Pletal)
C. Simvastatin (Zocor)
D. Clopidogrel (Plavix)
E. Warfarin (Coumadin)
F. Aspirin (acetylsalicylic acid)
A. Ramipril (Altace)
C. Simvastatin (Zocor)
F. Aspirin (acetylsalicylic acid)
Angiotensin-converting enzyme inhibitors (e.g., ramipril [Altace]) are used to control hypertension. Statins (e.g., simvastatin [Zocor]) are used for lipid management. Aspirin is used as an antiplatelet agent. Cilostazol (Pletal) is used for intermittent claudication, but it does not reduce CVD morbidity and mortality risks. Clopidogrel may be used if the patient cannot tolerate aspirin. Anticoagulants (e.g., warfarin [Coumadin]) are not recommended to prevent CVD events in PAD patients.
A patient was just diagnosed with acute arterial ischemia in the left leg secondary to atrial fibrillation. Which early clinical manifestation must be reported to the physician immediately to save the patient's limb?

A. Paralysis
B. Paresthesia
C. Crampiness
D. Referred pain
B. Paresthesia
The physician must be notified immediately if any of the six Ps of acute arterial ischemia occur to prevent ischemia from quickly progressing to tissue necrosis and gangrene. The six Ps are paresthesia, pain, pallor, pulselessness, and poikilothermia, with paralysis being a very late sign indicating the death of nerves to the extremity. Crampy leg sensation is more common with varicose veins. The pain is not referred.
A 40-year-old man tells the nurse he has a diagnosis for the color and temperature changes of his limbs but can't remember the name of it. He says he must stop smoking and avoid trauma and exposure of his limbs to cold temperatures to get better. This description should allow the nurse to ask the patient if he has which diagnosis?

A. Buerger's disease
B. Venous thrombosis
C. Acute arterial ischemia
D. Raynaud's phenomenon
A. Buerger's disease
Buerger's disease is a nonatherosclerotic, segmental, recurrent inflammatory disorder of small and medium-sized veins and arteries of upper and lower extremities leading to color and temperature changes of the limbs, intermittent claudication, rest pain, and ischemic ulcerations. It primarily occurs in men younger than 45 years old with a long history of tobacco and/or marijuana use. Buerger's disease treatment includes smoking cessation, trauma and cold temperature avoidance, and a walking program. Venous thrombosis is the formation of a thrombus in association with inflammation of the vein. Acute arterial ischemia is a sudden interruption in arterial blood flow to a tissue caused by embolism, thrombosis, or trauma. Raynaud's phenomenon is characterized by vasospasm-induced color changes of the fingers, toes, ears, and nose.
Which person should the nurse identify as having the highest risk for abdominal aortic aneurysm?

A. A 70-year-old male, with high cholesterol and hypertension
B. A 40-year-old female with obesity and metabolic syndrome
C. A 60-year-old male with renal insufficiency who is physically inactive
D. A 65-year-old female with hyperhomocysteinemia and substance abuse
A. A 70-year-old male, with high cholesterol and hypertension
The most common etiology of descending abdominal aortic aneurysm (AAA) is atherosclerosis. Male gender, age 65 years or older, and tobacco use are the major risk factors for AAAs of atherosclerotic origin. Other risk factors include the presence of coronary or peripheral artery disease, high blood pressure, and high cholesterol.
67-year-old man with peripheral artery disease is seen in the primary care clinic. Which symptom reported by the patient would indicate to the nurse that the patient is experiencing intermittent claudication?

A. Patient complains of chest pain with strenuous activity.
B. Patient says muscle leg pain occurs with continued exercise.
C. Patient has numbness and tingling of all his toes and both feet.
D. Patient states the feet become red if he puts them in a dependent position.
B. Patient says muscle leg pain occurs with continued exercise.
Intermittent claudication is an ischemic muscle ache or pain that is precipitated by a consistent level of exercise, resolves within 10 minutes or less with rest, and is reproducible. Angina is the term used to describe chest pain with exertion. Paresthesia is the term used to describe numbness or tingling in the toes or feet. Reactive hyperemia is the term used to describe redness of the foot; if the limb is in a dependent position the term is dependent rubor.
A 32-year-old female is prescribed diltiazem (Cardizem) for Raynaud's phenomenon. To evaluate the patient's expected response to this medication, what is most important for the nurse to assess?

A. Improved skin turgor
B. Decreased cardiac rate
C. Improved finger perfusion
D. Decreased mean arterial pressure
C. Improved finger perfusion
Raynaud's phenomenon is an episodic vasospastic disorder of small cutaneous arteries, most frequently involving the fingers and toes. Diltiazem (Cardizem) is a calcium channel blocker that relaxes smooth muscles of the arterioles by blocking the influx of calcium into the cells, thus reducing the frequency and severity of vasospastic attacks. Perfusion to the fingertips is improved and vasospastic attacks reduced. Diltiazem may decrease heart rate and blood pressure, but that is not the purpose in Raynaud's phenomenon. Skin turgor is most often a reflection of hydration status.
A 39-year-old woman with a history of smoking and oral contraceptive use is admitted with a venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory test should the nurse review to evaluate the expected effect of the heparin?

A. Platelet count
B. Activated clotting time (ACT)
C. International normalized ratio (INR)
D. Activated partial thromboplastin time (APTT)
D. Activated partial thromboplastin time (APTT)
Unfractionated heparin can be given by continuous IV for VTE treatment. When given IV, heparin requires frequent laboratory monitoring of clotting status as measured by activated partial thromboplastin time (aPTT). Platelet counts can decrease as an adverse reaction to heparin, but that is not the expected effect.
A 73-year-old man with dementia has a venous ulcer related to chronic venous insufficiency. The nurse should provide education on which type of diet for this patient and his caregiver?

A. Low-fat diet
B. High-protein diet
C. Calorie-restricted diet
D. High-carbohydrate diet
B. High-protein diet
A patient with a venous ulcer should have a balanced diet with adequate protein, calories, and micronutrients; this type of diet is essential for healing. Nutrients most important for healing include protein, vitamins A and C, and zinc. Foods high in protein (e.g., meat, beans, cheese, tofu), vitamin A (green leafy vegetables), vitamin C (citrus fruits, tomatoes, cantaloupe), and zinc (meat, seafood) must be provided. Restricting fat or calories is not helpful for wound healing or in patients of normal weight. For overweight individuals with no active venous ulcer, a weight-loss diet should be considered.
The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT). The patient now needs to undergo surgery for appendicitis. The nurse is reviewing the laboratory results for this patient before administering an ordered dose of vitamin K. The nurse determines that the medication is both safe to give and is most needed when the international normalized ratio (INR) is which result?
A) 1.0
B) 1.2
C) 1.6
D) 2.2
D) Vitamin K is the antidote to warfarin (Coumadin), which the patient has most likely been taking before admission for treatment of DVT. Warfarin is an anticoagulant that impairs the ability of the blood to clot. Therefore it is necessary to give vitamin K before surgery to reduce the risk of hemorrhage. The largest value of the INR indicates the greatest impairment of clotting ability, making 2.2 the correct selection.
What is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)?
A) Application of topical antibiotics to venous ulcers
B) Maintaining the patient's legs in a dependent position
C) Administration of oral and/or subcutaneous anticoagulants
D) Teaching the patient the correct use of compression stockings
D) CVI requires conscientious and consistent application of compression stockings. Anticoagulants are not necessarily indicated and antibiotics, if required, are typically oral or IV, not topical. The patient should avoid prolonged positioning with the limb in a dependent position.
A female patient with critical limb ischemia has had peripheral artery bypass surgery to improve her circulation. What care should the nurse provide on postoperative day 1?
A) Keep the patient on bed rest.
B) Assist the patient with walking several times.
C) Have the patient sit in the chair several times.
D) Place the patient on her side with knees flexed.
B) To avoid blockage of the graft or stent, the patient should walk several times on postoperative day 1 and subsequent days. Having the patient's knees flexed for sitting in a chair or in bed increase the risk of venous thrombosis and may place stress on the suture lines.
A male patient was admitted for a possible ruptured aortic aneurysm, but had no back pain. Ten minutes later his assessment includes the following: sinus tachycardia at 138, BP palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret this assessment about the patient's aneurysm?
A) Tamponade will soon occur.
B) The renal arteries are involved.
C) Perfusion to the legs is impaired.
D) He is bleeding into the abdomen.
D) The lack of back pain indicates the patient is most likely exsanguinating into the abdominal space, and the bleeding is likely to continue without surgical repair. A blockade of the blood flow will not occur in the abdominal space as it would in the retroperitoneal space where surrounding anatomic structures may control the bleeding. The lack of urine output does not indicate renal artery involvement, but that the bleeding is occurring above the renal arteries, which decreases the blood flow to the kidneys. There is no assessment data indicating decreased perfusion to the legs.
The patient had aortic aneurysm repair. What priority nursing action will the nurse use to maintain graft patency?
A. Assess output for renal dysfunction.
B. Use IV fluids to maintain adequate BP.
C. Use oral antihypertensives to maintain cardiac output.
D. Maintain a low BP to prevent pressure on surgical site
B) The priority is to maintain an adequate BP (determined by the surgeon) to maintain graft patency. A prolonged low BP may result in graft thrombosis, and hypertension may cause undue stress on arterial anastomoses resulting in leakage of blood or rupture at the suture lines, which is when IV antihypertensives may be used. Renal output will be assessed when the aneurysm repair is above the renal arteries to assess graft patency, not maintain it.
When the patient is being examined for venous thromboembolism (VTE) in the calf, what diagnostic test should the nurse expect to teach the patient about first?
A) Duplex ultrasound
B) Contrast venography
C) Magnetic resonance venography
D) Computed tomography venography
A) The duplex ultrasound is the most widely used test to diagnose VTE. Contrast venography is rarely used now. Magnetic resonance venography is less accurate for calf veins than pelvic and proximal veins. Computed tomography venography may be used but is invasive and much more expensive than the duplex ultrasound.
The patient reports tenderness when she touches her leg over a vein. The nurse assesses warmth and a palpable cord in the area. The nurse knows the patient needs treatment to prevent which sequelae?
A. Pulmonary embolism
B. Pulmonary hypertension
C. Post-thrombotic syndrome
D. Venous thromboembolism
D) The clinical manifestations are characteristic of a superficial vein thrombosis. If untreated, the clot may extend to deeper veins, and venous thromboembolism may occur. Pulmonary embolism, pulmonary hypertension, and post-thrombotic syndrome are the sequelae of venous thromboembolism.
The patient has CVI and a venous ulcer. The unlicensed assistive personnel (UAP) decides to apply compression stockings because that is what these patients always have ordered. What assessment by the nurse would cause the application of compression stockings to harm the patient?
A) Rest pain
B) High blood pressure
C) Elevated blood sugar
D) Dry, itchy, flaky skin
A) Rest pain occurs as peripheral artery disease (PAD) progresses and involves multiple arterial segments. Compression stockings should not be used on patients with PAD. Elevated blood glucose, possibly indicating uncontrolled diabetes mellitus, and hypertension may or may not indicate arterial problems. Dry, itchy, flaky skin indicates venous insufficiency. The RN should be the one to obtain the order and instruct the UAP to apply compression stockings if they are ordered.
The nurse is reviewing the laboratory test results for a 68-yr-old patient whose warfarin (Coumadin) therapy was terminated during the preoperative period. On postoperative day 2, the international normalized ratio (INR) result is 2.7. Which action by the nurse is most appropriate?
A) Hold the daily dose of warfarin.
B) Administer the daily dose of warfarin.
C) Teach the patient signs and symptoms of bleeding.
D) Call the physician to request an increased dose of warfarin.
B

The therapeutic range for INR is 2.0 to 3.0 for many clinical diagnoses. To maintain therapeutic values, the nurse will administer the medication as ordered. Holding the medication would lower the INR, which would increase the risk of clot formation. Conversely, the higher the INR is, the more prolonged the clotting time. Calling the health care provider is not indicated. Although teaching is important, administering the medication is a higher priority at this time.
Which assessment findings of the left lower extremity will the nurse identify as consistent with arterial occlusion (select all that apply.)?
A) Edematous
B) Cold and mottled
C) Complaints of paresthesia
D) Pulse not palpable with Doppler
E) Capillary refill less than three seconds
F) Erythema and warmer than right lower extremity
BCD

Arterial occlusion may result in loss of limb if not timely revascularized. When an artery is occluded, perfusion to the extremity is impaired or absent. On assessment, the nurse would note a cold, mottled extremity with impaired sensation or numbness. The pulse would not be identified, even with a Doppler. In contrast, the nurse would find edema, erythema, and increased warmth in the presence of a venous occlusion (deep vein thrombosis). Capillary refill would be greater than 3 seconds in an arterial occlusion and less than 3 seconds with a venous occlusion.
The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT) who is scheduled for an emergency appendectomy. Vitamin K is ordered for immediate administration. The international normalized ratio (INR) value is 1.0. Which nursing action is most appropriate?
A) Administer the medication as ordered.
B) Hold the medication and record in the electronic medical record.
C) Hold the medication until the lab result is repeated to verify results.
D) Administer the medication and seek an increased dose from the health care provider.
B
Hold the medication and record in the electronic medical record. Vitamin K is the antidote to warfarin (Coumadin), which the patient has most likely been taking before admission for treatment of DVT. Warfarin is an anticoagulant that impairs the ability of the blood to clot. Therefore, it may be necessary to give vitamin K before surgery to reduce the risk of hemorrhage. However, the INR value is normal, and vitamin K is not required, so the medication would be held and recorded in the electronic medical record.
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