Vascular Assessment
This assessment compares blood flow to the extremities by evaluating pulse strength, skin temperature, color, and capillary refill.
What is Peripheral vascular assessment?
What is the hallmark description of pain associated with an aortic dissection?
Sudden severe tearing or ripping chest pain radiating to the back.
Which laboratory test measures oxygen-carrying capacity?
Hemoglobin.
Which disorder is characterized by autoimmune destruction of platelets?
Immune Thrombocytopenia (ITP).
A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with iron deficiency anemia reporting fatigue after walking to the bathroom.
B. A client with immune thrombocytopenia (ITP) whose platelet count decreased from 45,000/µL to 32,000/µL overnight and has new petechiae.
C. A client receiving heparin whose platelet count has decreased from 250,000/µL to 110,000/µL over 48 hours and now reports new right calf pain.
D. A client with hemophilia requesting pain medication for chronic joint pain.
Answer: C
Rationale: The client receiving heparin is exhibiting classic findings of heparin-induced thrombocytopenia (HIT) with suspected thrombosis. Although thrombocytopenic, the greatest immediate risk is life-threatening thromboembolism, making this the highest-priority assessment.
A patient has a cool, pale foot with diminished pedal pulses and delayed capillary refill. This is more consistent with arterial or venous disease...
What is Arterial disease?
Which assessment finding is most characteristic of an abdominal aortic aneurysm?
A pulsatile abdominal mass.
Which laboratory value is most useful for evaluating platelet function and bleeding risk?
Platelet count.
A patient receiving heparin develops thrombocytopenia and a new deep vein thrombosis. Which condition should the nurse suspect?
Heparin-Induced Thrombocytopenia (HIT).
Which nursing diagnosis is the highest priority for a patient experiencing severe blood loss?
Ineffective Tissue Perfusion.
Which assessment finding is considered normal during a peripheral vascular examination?
A. Capillary refill of 5 seconds
B. Bilateral 2+ pulses
C. Cyanotic toes
D. Absent dorsalis pedis pulse
B. Bilateral 2+ pulses.
Which finding is most concerning in a patient with chest pain?
A. Pain relieved by rest
B. Equal blood pressures in both arms
C. Blood pressure difference between arms
D. Heart rate of 72 bpm
C. Blood pressure difference between arms
Match the medication with the laboratory value.
Warfarin = ?
Heparin = ?
Warfarin → PT/INR
Heparin → aPTT
Which coagulation disorder commonly presents with spontaneous bleeding into joints?
Hemophilia.
A neutropenic patient develops a temperature of 101.5°F (38.6°C). What is the nurse's priority action?
Notify the healthcare provider immediately, initiate neutropenic precautions, and anticipate obtaining cultures and administering prescribed antibiotics.
Name four abnormal findings that indicate decreased peripheral perfusion.
A patient with an aortic dissection becomes hypotensive, confused, and has cool, mottled skin. What complication is the nurse most concerned about?
Shock resulting from progression of the dissection or rupture.
Which laboratory findings suggest iron deficiency anemia?
A patient has petechiae, normal PT, normal aPTT, and a platelet count of 18,000/µL. Which disorder is most likely?
Immune Thrombocytopenia (ITP).
A 72-year-old patient with hypertension suddenly develops severe "tearing" chest pain that radiates to the back. The right arm blood pressure is 196/108 mmHg, the left arm blood pressure is 160/88 mmHg, the patient is diaphoretic, and the left radial pulse is diminished. Laboratory results include hemoglobin 14.1 g/dL, platelets 215,000/µL, and INR 3.5.
Question: Identify the most likely diagnosis and list three immediate nursing priorities.
Diagnosis: Acute aortic dissection.
Immediate Priorities:
A nurse notes that a patient's right pedal pulse is absent while the left pedal pulse is 2+. What is the nurse's priority action?
Assess the extremity for additional signs of ischemia and notify the healthcare provider immediately.
List five priority nursing interventions for a patient with a suspected aortic dissection.
A patient's laboratory results show:
Platelets ↓
PT ↑
aPTT ↑
D-dimer ↑
Fibrinogen ↓
Which disorder should the nurse suspect?
Disseminated Intravascular Coagulation (DIC).
Compare ITP and HIT by identifying the primary complication associated with each disorder.
A patient admitted with disseminated intravascular coagulation (DIC) has the following assessment findings:
Which nursing intervention should the nurse implement first?
A. Administer prescribed analgesics.
B. Encourage oral fluids.
C. Assess airway, circulation, and signs of active bleeding while preparing blood products as prescribed.
D. Teach the patient about bleeding precautions.
Answer: C
Rationale: The patient is demonstrating active bleeding and hemodynamic instability consistent with severe DIC. Immediate stabilization of circulation and preparation for replacement of blood components are the priority.