Risks
A Nurse is caring for a patient with poor tissue perfusion related to peripheral vascular disease (PVD) who has ulcers on the toes. Which of the following finding is a risk factor for developing ulcerations of the extremities?
A. Poor skin care
B. Impaired circulation
C. Immobility
D. Dehydration
B. Impaired circulation
Prolonged problems with tissue perfusion related to PVD can contribute to the formation of ulcerations. The severity of PVD should be identified through assessment of strength and symmetry of peripheral pulses.
The nurse is assessing a patient, who has many risk factors for the development of a DVT. What signs and symptoms below would possibly indicate a DVT is present? (Select all that apply)
A. Cool extremity
B. Decreased pulses
C. Redness
D. Pain
E. Warm extremity
F. Swelling
G. Cyanosis
C. Redness
D. Pain
E. Warm extremity
F. Swelling
s/s of DVT include: redness, swelling, warm extremity, pain, and swelling (which can be unilateral, meaning there is more swelling in one extremity compared to the other)
The nurse is caring for a patient at high risk of developing a DVT. what nursing intervention is appropriate for the nurse to take to help prevent a DVT from forming?
A. Collaborating with a registered dietician to provide the patient with a normal diet.
B. Instruct the patient to cross their legs in bed
C. Applying Sequential Compression Device (SCD's) on the patient
D. Apply a cold compress on the patient's legs
C. Applying Sequential Compression Device (SCD's) on the patient
Sequential Compression Device (SCD) is a method of DVT prevention that improves blood flow in the legs. SCD's are shaped like “sleeves” that wrap around the legs and inflate with air one at a time. This imitates walking and helps prevent blood clots.
A nurse is providing education about continuous heparin therapy for a patient with deep vein thrombosis DVT. What should be included in the teaching?
A. Avoid taking acetaminophen while taking this medication.
B. This medication will require monitoring of WBCs
C. This medication can make you drowsy
D. Use a soft toothbrush and gently brush your teeth while taking this medication.
D. Use a soft toothbrush and gently brush your teeth while taking this medication.
Bleeding is a side effect when taking this medication, extra care should be taken to avoid bleeding gums.
A nurse is caring for a patient who has a below the knee amputation for gangrene of the left foot. The patient reports feelings of pain and tingling in the absent foot. How should the nurse respond?
A. "A cold compress should help with the pain."
B. "This type of pain should decrease over time as the limb becomes less sensitive."
C. "Sometimes grief over the loss of a limb can cause denial."
D. "Try and remember that the limb is gone."
B. "This type of pain should decrease over time as the limb becomes less sensitive."
Phantom limb pain is a common complication of amputation and includes numbness, tingling, and a sharp burning pain. This type of pain typically weakens over time.
A nurse is caring for a client who is being screened for atherosclerosis. Which value should be identified as a risk for this disorder?
A. LDL 125mg/dL
B. HDL 45mg/dL
C. Cholesterol level 195mg/dL
D. Triglyceride level 140mg/dL
A. LDL 125mg/dL
Elevated LDL is a risk factor for atherosclerosis. An optimal level of LDL is <100mg/dL.
The nurse is assessing a patient with impaired tissue perfusion from cardiac ischemia. What are some signs that a nurse will look for in the patient? (Select all that apply)
A. Capillary refill less than 3 seconds
B. Tachycardia
C. Chest pain
D. Bradycardia
B. Tachycardia
C. Chest pain
Myocardial ischemia, also called cardiac ischemia, reduces the heart muscle's ability to pump blood. Because of this, the patient can experience tachycardia and chest pain.
B. Massage affected limbs
C. Provide exposure to cold temperatures.
D. Provide the patient with SCD's
D. Provide the patient with SCD's
Cold temperatures create vasoconstriction and can increase the patients' risk to developing a DVT. Massaging the affected limbs can cause a thrombosis to dislodge, possibly leading to pulmonary embolism. In order to promote vasodilation, it is best to provide a warm environment and apply SCD's on patient to improve blood circulation.
A client who has a prescription for heparin via continuous IV infusion for thrombophlebitis should include which of these in their plan of care?
A. Infuse the heparin using an electronic IV pump
B. Administer vitamin K if the Clint has indications of hemorrhage
C. Adjust the dosage of heparin based on the client's PT levels
D. Inform the client that the heparin will dissolve the thrombus
A. Infuse the heparin using an electronic IV Pump
The nurse should administer heparin using an electronic IV pump, rather than gravity, to prevent an accidental increase or change in the rate of infusion.
A client who had a myocardial infarction is being monitored by the nurse. The nurse monitors in the first 24 hr which of the following complications?
A. Infective endocarditis
B. Pericarditis
C. Ventricular dysrhythmias
D. Pulmonary emboli
C. Ventricular dysrhythmias
After an MI, the electrical conduction system of the heart can be irritable and prone to dysrhythmias. Ischemic tissue caused by the infection can also interfere with normal conduction pattern of the heart's electrical system.
When caring for an older adult patient who has had an MI the nurse should know the patient is at risk for complications of MI from poor tissue perfusion because of what age related change?
A. Increased peripheral vascular resistance
B. Increased sensitivity of baroreceptors
C. Decreased sensitivity to cardiac medication
D. Increased clotting time
A. Increased peripheral vascular resistance
Calcification and decreased elasticity of vessels occurs with aging. This causes an increase in peripheral vascular resistance which puts the patient at risk for complications following MI
The nurse is preparing to conduct an assessment on a patient with a history of DM2 who has presented into the ER with complaints of losing sensation on his right big toe and noticing his skin turning a dark black color. What type of focused assessment should the nurse conduct?
A. Cardiac assessment
B. Integumentary assessment
C. Neurovascular assessment
D. Musculoskeletal assessment
C. Neurovascular assessment
A focused neurovascular assessment is ideal for a patient experiencing impaired tissue perfusion. The neurovascular assessment consists of the 6Ps (pallor, pulses, poikilothermia, paralysis, paresthesia, and pallor)
The nurse is getting ready to educate a patient with a history of hypertension on how to improve their diet to help treat or prevent high blood pressure. Which diet is ideal for the nurse to educate the patient on?
A. High-carb diet
B. High-sugar diet
C. Full liquid diet
D. DASH diet
D. DASH diet
The DASH diet is a dietary pattern promoted by the U.S.-based National Heart, Lung, and Blood Institute to prevent and control hypertension. The DASH diet is rich in fruits, vegetables, whole grains, and low-fat dairy foods.
A nurse is caring for a client who had an MI 2 hours prior and is receiving alteplase. Which of the following findings should the nurse identify as an adverse effect of receiving this medication?
A. Bleeding
B. Increase clot formation
C. Shortness of breath
D. Blockage of the central venous catheter
A. Bleeding
The nurse should identify that an adverse effect of alteplase is bleeding. Severe bleeding can occur as a result of the alteplase-plasminogen complex, which catalyzes the conversion of other plasminogen molecules that digest fibrin clots. This action of the medication can contribute to hemorrhage.
A client with deep-vein thrombosis in her left calf is being assessed by the nurse. The nurse should expect to find which of the following manifestations? (Select all that apply)
A. Hardening along the blood clot
B. Absence of peripheral pulse
C. Tenderness in the calf
D. Cool skin on the leg
E. Increased leg circumference
A. Hardening along the blood clot
C.Tenderness in the calf
E. Increased leg circumference
DVT can cause hardening along the affected blood vessel and prominence of superficial veins, pain or tenderness in the calf, and an increase in the circumference of the leg due to swelling.