The nurse is assessing a 48-year-old client with a history of smoking during a
routine clinic visit. The client, who exercises regularly, reports having p... [Show More] ain in the calf
during exercise that disappears at rest. Which of the following findings requires further
evaluation?
1. Heart rate 57 bpm.
2. SpO2 of 94% on room air.
3. Blood pressure 134/82.
4. Ankle-brachial index of 0.65. - 4
An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular disease in
a client who is experiencing intermittent claudication. A Doppler ultrasound is
indicated for further evaluation. The bradycardic heart rate is acceptable in an athletic
client with a normal blood pressure. The SpO2 is acceptable; the client has a smoking
history.
An overweight client taking warfarin (Coumadin) has dry skin due to decreased
arterial blood flow. What should the nurse instruct the client to do? Select all that apply.
1. Apply lanolin or petroleum jelly to intact skin.
2. Follow a reduced-calorie, reduced-fat diet.
3. Inspect the involved areas daily for new ulcerations.
4. Instruct the client to limit activities of daily living (ADLs).
5.Use an electric razor to shave - 1,2,3,5
Maintaining skin integrity is important in preventing chronic ulcers and
infections. The client should be taught to inspect the skin on a daily basis. The client
should reduce weight to promote circulation; a diet lower in calories and fat is
appropriate. Because the client is receiving Coumadin, the client is at risk for bleeding
from cuts. To decrease the risk of cuts, the nurse should suggest that the client use an
electric razor. The client with decreased arterial blood flow should be encouraged to
participate in ADLs. In fact, the client should be encouraged to consult an exercise
physiologist for an exercise program that enhances the aerobic capacity of the body.
A client with peripheral vascular disease has undergone a right femoral-popliteal
bypass graft. The blood pressure has decreased from 124/80 to 94/62. What
should the nurse assess first?
1. IV fluid solution.
2. Pedal pulses.
3. Nasal cannula flow rate.
4. Capillary refill - 2
With each set of vital signs, the nurse should assess the dorsalis pedis and
posterior tibial pulses. The nurse needs to ensure adequate perfusion to the lower
extremity with the drop in blood pressure. IV fluids, nasal cannula setting, and capillary
refill are important to assess; however, priority is to determine the cause of drop in
blood pressure and that adequate perfusion through the new graft is maintained.
The nurse is caring for a client with peripheral artery disease who has recently
been prescribed clopidogrel (Plavix). The nurse understands that more teaching is
necessary when the client states which of the following:
1. "I should not be surprised if I bruise easier or if my gums bleed a little when
brushing my teeth."
2. "It doesn't really matter if I take this medicine with or without food, whatever
works best for my stomach."
3. "I should stop taking Plavix if it makes me feel weak and dizzy."
4. "The doctor prescribed this medicine to make my platelets less likely to stick together and help
prevent clots from forming." - 3
Weakness, dizziness, and headache are common adverse effects of Plavix and
the client should report these to the physician if they are problematic; in order to
decrease risk of clot formation, Plavix must be taken regularly and should not be
stopped or taken intermittently. The main adverse effect of Plavix is bleeding, which
often occurs as increased bruising or bleeding when brushing teeth. Plavix is well
absorbed, and while food may help decrease potential gastrointestinal upset, Plavix may
be taken with or without food. Plavix is an antiplatelet agent used to prevent clot
formation in clients who have experienced or are at risk for myocardial infarction,
ischemic stroke, peripheral artery disease, or acute coronary syndrome.
A client is receiving Cilostazol (Pletal) for peripheral arterial disease causing
intermittent claudication. The nurse determines this medication is effective when the
client reports which of the following?
1. "I am having fewer aches and pains."
2. "I do not have headaches anymore."
3. "I am able to walk further without leg pain."
4. "My toes are turning grayish black in color." - 3
Cilostazol is indicated for management of intermittent claudication. Symptoms
usually improve within 2 to 4 weeks of therapy. Intermittent claudication prevents
clients from walking for long periods of time. Cilostazol inhibits platelet aggregation
induced by various stimuli and improving blood flow to the muscles and allowing the
client to walk long distances without pain. Peripheral arterial disease causes pain
mainly of the leg muscles. "Aches and pains" does not specify exactly where the pain is
occurring. Headaches may occur as a side effect of this drug, and the client should
report this information to the health care provider. Peripheral arterial disease causes
decreased blood supply to the peripheral tissues and may cause gangrene of the toes; the
drug is effective when the toes are warm to the touch and the color of the toes is similar
to the color of the body.
The client admitted with peripheral vascular disease (PVD) asks the nurse why
her legs hurt when she walks. The nurse bases a response on the knowledge that the
main characteristic of PVD is:
1. Decreased blood flow.
2. Increased blood flow.
3. Slow blood flow.
4. Thrombus formation. - 1
Decreased blood flow is a common characteristic of all PVD. When the
demand for oxygen to the working muscles becomes greater than the supply, pain is the
outcome. Slow blood flow throughout the circulatory system may suggest pump failure.
Thrombus formation can result from stasis or damage to the intima of the vessels.
The nurse is planning care for a client who is diagnosed with peripheral vascular
disease (PVD) and has a history of heart failure. The nurse should develop a plan of
care that is based on the fact that the client may have a low tolerance for exercise
related to:
1. Decreased blood flow.
2. Increased blood flow.
3. Decreased pain.
4. Increased blood viscosity. - 1
A client with PVD and heart failure will experience decreased blood flow. In
this situation, low exercise tolerance (oxygen demand becomes greater than the oxygen
supply) may be related to less blood being ejected from the left ventricle into the
systemic circulation. Decreased blood supply to the tissues results in pain. Increased
blood viscosity may be a component, but it is of much less importance than the disease
processes.
When assessing the lower extremities of a client with peripheral vascular
disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:
1. Competent venous valves.
2. Decreased blood volume.
3. Increase in muscular activity.
4. Increased venous pressure. - 4
In PVD, decreased blood flow can result in increased venous pressure. The
increase in venous pressure results in an increase in capillary hydrostatic pressure,
which causes a net filtration of fluid out of the capillaries into the interstitial space,
resulting in edema. Valves often become incompetent with PVD. Blood volume is not
decreased in this condition. Decreased muscular action would contribute to the
formation of edema in the lower extremities.
The nurse is obtaining the pulse of a client who has had a femoral-popliteal
bypass surgery 6 hours ago. (See below) Which assessment provides the most accurate
information about the client's postoperative status?
1. radial pulse
2. femoral pulse
3. apical pulse
4. dorsalis pedis pulse - 4
The presence of a strong dorsalis pedis pulse indicates that there is circulation to
the extremity distal to the surgery indicating that the graft between the femoral and
popliteal artery is allowing blood to circulate effectively. Answer 1 shows the nurse
obtaining the radial pulse; answer 2 shows the femoral pulse, which is proximal to the
surgery site and will not indicate circulation distal to the surgery site. Answer 3 shows
the nurse obtaining an apical pulse.
The nurse is teaching a client about risk factors associated with atherosclerosis
and how to reduce the risk. Which of the following is a risk factor that the client is not
able to modify?
1. Diabetes.
2. Age.
3. Exercise level.
4. Dietary preferences - 2
Age is a nonmodifiable risk factor for atherosclerosis. The nurse instructs the
client to manage modifiable risk factors such as comorbid diseases (eg, diabetes),
activity level, and diet. Controlling serum blood glucose levels, engaging in regular
aerobic activity, and choosing a diet low in saturated fats can reduce the risk of
developing atherosclerosis. [Show Less]
