A
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
Rationale: 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.
What is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)?
a. Applying topical antibiotics to venous ulcers
b. Maintaining the patient’s legs in a dependent position
c. Administering oral and/or subcutaneous anticoagulants
d. Teaching the patient the correct use of compression stockings
d. Teaching the patient the correct use of compression stockings
Rationale: 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
The patient had aortic aneurysm repair 6 hours ago. What priority nursing action will 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. Use IV fluids to maintain adequate BP
Rationale: The priority is to maintain an adequate blood pressure (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.
The nurse is admitting a preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) daily. 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
Rationale: 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).
A 62-yr-old Hispanic male patient with diabetes has been diagnosed with peripheral artery disease (PAD). The patient smokes and has a history of gout. To prevent complications, which factor is priority in patient teaching?
a. Gender
b. Smoking
c. Ethnicity
d. Comorbidities
b. Smoking
Rationale: 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 and hyperuricemia are also risk factors. Being male or Hispanic are not risk factors for PAD.
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 provider to save the patient’s limb?
a. Paralysis
b. Cramping
c. Paresthesia
d. Referred pain
c. Paresthesia
Rationale: The provider 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 postoperative patient asks the nurse why the provider ordered daily administration of enoxaparin (Lovenox). Which reply by the nurse is accurate?
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."
Rationale: Enoxaparin is an anticoagulant that is used to prevent DVTs postoperatively. All other options do not describe the action or purpose of enoxaparin.
A patient is prescribed diltiazem (Cardizem) for Raynaud’s phenomenon. Which assessment finding would indicate to the nurse that the medication is effective?
a. Improved skin turgor
b. Decreased cardiac rate
c. Improved finger perfusion
d. Decreased mean arterial pressure
c. Improved finger perfusion
Rationale: 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 are 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.
The nurse observes that phlebitis has developed at a patient’s peripheral IV site 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
Rationale: The priority intervention for superficial phlebitis is removal of the offending IV catheter. Decreasing the IV rate is insufficient. Anticoagulants are not normally required, and warm, moist heat is often therapeutic.
A patient with critical limb ischemia had peripheral artery bypass surgery to improve circulation. What nursing care should be provided on the first postoperative day?
a. Keep patient on bed rest.
b. Assist patient to walk several times.
c. Have patient sit in the chair several times.
d. Place patient on their side with knees flexed
b. Assist patient to walk several times
Rationale: To avoid blockage of the graft or stent, the patient should walk several times on postoperative day one 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.
What medications should the nurse expect to include in the teaching plan to decrease the risk of cardiovascular events and death for patients with PAD? (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)
d. Clopidogrel (Plavix)
f. Aspirin (acetylsalicylic acid)
Rationale: 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. Clopidogrel may be used if the patient cannot tolerate aspirin. Cilostazol (Pletal) is used for intermittent claudication, but it does not reduce CVD morbidity and mortality risks. Anticoagulants (e.g., warfarin [Coumadin]) are not recommended to prevent cardiovascular disease events in PAD patients.
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
Rationale: 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.
Which assessment findings of the left lower extremity would the nurse identify as consistent with arterial occlusion? (Select all that apply.)
a. Edematous
b. Cold and mottled
c. Reports of paresthesia
d. Pulse not palpable with Doppler
e. Warmer than right lower extremity
f. Capillary refill less than 3 seconds
b. Cold and mottled
c. Reports of paresthesia
d. Pulse not palpable with Doppler
Rationale: 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.
Which person would the nurse identify as having the highest risk for abdominal aortic aneurysm?
a. A 70-yr-old man with high cholesterol and hypertension
b. A 40-yr-old woman with obesity and metabolic syndrome
c. A 60-yr-old man with renal insufficiency who is physically inactive
d. A 65-yr-old woman with high homocysteine levels and substance use
a. A 70-year-old man with high cholesterol and hypertension
Rationale: The most common cause 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.
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 consequence?
a. Pulmonary embolism
b. Pulmonary hypertension
c. Postthrombotic syndrome
d. Venous thromboembolism
d. Venous thromboembolism
Rationale: The 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 postthrombotic syndrome are the sequelae of venous thromboembolism.
The nurse is reviewing the laboratory test results for a patient whose warfarin (Coumadin) therapy was stopped before surgery. 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 health care provider to request an increased dose of warfarin
b. Administer the daily dose of warfarin
Rationale: 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 finding would alert the nurse that a postoperative patient is not receiving the beneficial effects of enoxaparin (Lovenox)?
a. Crackles bilaterally in the lung bases
b. Pain and swelling in a lower extremity
c. Absence of arterial pulse in a lower extremity
d. Abdominal pain with decreased bowel sounds
b. Pain and swelling in a lower extremity
Rationale: 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 a lower extremity can indicate development of DVT and therefore may signal ineffective medication therapy.
The nurse is caring for a patient who has been receiving warfarin (Coumadin) and diltiazem (Cardizem) 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
Rationale: Warfarin is an anticoagulant that is used to prevent thrombi from forming on the walls of the atria during atrial fibrillation. When 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.
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. Duplex ultrasound
Rationale: 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.
A patient with varicose veins has been prescribed compression stockings. Which nursing instruction would be appropriate?
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 several times a day.”
b. "While you're still lying in bed in the morning, put on your stockings."
Rationale: The patient with varicose veins should apply stockings in bed before rising in the morning. Stockings should not be worn continuously and should not be removed several times daily. Dangling at the bedside before application is likely to decrease their effectiveness.
An older adult with dementia has a venous ulcer related to chronic venous insufficiency. The nurse should provide teaching 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
Rationale: 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.
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 in away from a mole
d. Anterolateral thigh, with no scar tissue nearby
b. Abdomen, anterior-lateral aspect
Rationale: 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.
A patient was admitted for possible ruptured aortic aneurysm. Ten minutes later, the nurse notes sinus tachycardia 138 beats/min, blood pressure is palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret the findings?
a. Tamponade will soon occur.
b. The renal arteries are involved.
c. Perfusion to the legs is impaired.
d. Bleeding into the abdomen is likely
d. Bleeding into the abdomen is likely
Rationale: The patient is likely bleeding into the abdominal space, and it 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 are no assessment data indicating decreased perfusion to the legs.
A patient 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 reports chest pain with strenuous activity.
b. Patient says muscle leg pain occurs with continued exercise.
c. Patient has numbness and tingling of all their toes and both feet.
d. Patient states the feet become red when they are in a dependent position
b. Patient says muscle leg pain occurs with continued exercise
Rationale: 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 39-yr-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)
Rationale: 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.