Peripheral Aterial Disease Risk Factors - Answers Smoking, Hypertension, Diabetes
Vital signs in PAD - Answers decreased or absent pulses, cold, pallor increased, rubor decreased,
increased pain
Symptoms of PAD - Answers Dry skin, dry/necrotic ulcers, numbness/tingling, pain "intermittent
claudication"
Do you want to elevate the legs of a person with PAD? - Answers No. They are having a problem
pushing the blood away from the heart. Elevation will further complicate this problem.
Peripheral Venous Disease Risk Factors - Answers Occupation (standing for long time), hypertension,
obesity, pregnancy
Vital signs in PVD - Answers Pulses raise, warm, edema
Symptoms of PVD - Answers moist ulcers located on the malleolar
Do you want to elevate the legs of someone with PVD? - Answers Yes, this intervention will help
return blood to the heart. Also Ted Hose will help.
What are both PVD and PAD at risk for? - Answers Because of numb/edema/ulcers they are both at
risk for impaired skin integrity... so you need to assess the feet and constantly wear shoes.
Venous Thromboembolism - Answers Pulmonary Embolism, Deep Vein Thrombosis
DVT - Answers Unilateral pulse change, redness/erythema, warmth
VTE Risk Factors - Answers Decreased mobility, decreased circulation, Birth Control Pills
Prevention of DVTs - Answers blood thinners, Ted hose/SCD's, mobile
If the prevention does not work and treatment of a DVT is required, what is contraindicated? -
Answers Do not massage, do not mobilize, do not wear Ted/SCD's
Petechiae - Answers Small leaks in the capillaries, causing bleeding under the skin. Occur with PE over
hours or days.
PE Clinical Manifestations - Answers Dyspnea, Chest pain & hemoptysis
Restlessness/Anxious
Air Hunger
Change in LOC
Cough
Tachypnea
Tachycardia
Hypotension
Decreasing Pulse Ox
Crackles
Cyanosis
Petechiae
Murmur - S3&4
Causes of PE (other than a dislodged DVT) - Answers Surgery
Bed rest- Immobility
Tobacco use
Heart failure/ Atrial Fibrillation
Lower extremity fracture
Contraception/ estrogen therapy: causes clotting
Pregnancy
Hypercoagulability
Normal INR clotting times
&
What do you want the INR clotting time to be for a PE? - Answers 1.5 - 2
2 - 3 * because we want them to take longer to clot
In the heart rhythm, what sound is the loudest? - Answers The Lub is always louder than the Dub
Where are the heart sounds best heard? - Answers Apex
When should you take an apical pulse over radial? - Answers When the patient is on heart controlling
medications
Opioids antidote - Answers Narcan
Blood thinners antidote - Answers Vitamin K
, A nurse on the medical-surgical unit just received report on her client care assignment. Which client
should she assess first?
A) The client with anorexia, weight loss, and night sweats.
B) The client with crackles and fever who is complaining of pleuritic pain.
C) The client who had difficulty sleeping, daytime fatigue, and morning headache.
D) The client with unilateral leg swelling who's complaining of anxiety and shortness of breath. -
Answers D
A patient with thrombophlebitis reached her expected outcomes of care. Her affected leg appears
pink and warm. Her pedal pulse is palpable and there is no edema present. Which step in the nursing
process is described above?
A) Planning
B) Implementation
C) Assessment
D) Evaluation - Answers D
A female client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that
which of the following is a common clinical manifestation of pulmonary embolism?
a. Dyspnea
b. Bradypnea (tachy)
c. Bradycardia (tachy)
d. Decreased respiratory effort (increased) - Answers A
The nurse puts elastic stockings on a client following major abdominal surgery. The nurse teaches the
client that the stocking are used for:
A. Prevent varicose veins
B. Prevent muscular atrophy
C Facilitate the return of venous blood to the heart
D. Ensure joint mobility & prevent contractures - Answers C
A patient with peripheral vascular disease has marked peripheral neuropathy. An appropriate nursing
diagnosis for the patient is:
A. Risk for injury related to decreased sensation.
B. Impaired skin integrity related to decreased peripheral circulation.
C. Ineffective peripheral tissue perfusion related to decreased arterial blood flow.
D. Activity intolerance related to imbalance between oxygen supply and demand. - Answers A
When teaching a patient with peripheral arterial disease, the nurse determines that further teaching
is needed when the patient says,
A. "I should not use heating pads to warm my feet."
B. "I will examine my feet every day for any sores or red areas."
C. "I should cut back on my walks if they cause pain in my legs."
D. "I think I can quit smoking with the use of short-term nicotine replacement and support groups." -
Answers C
Following an aortic aneurysm repair, the patient suddenly develops severe pain in the right lower
extremity. The right pedal pulse is decreased, and the right foot is cool and pale. The nurse suspects
A. hypothermia.
B. a wound infection.
C. bleeding from the graft site.
D. an embolization or graft occlusion. - Answers D
Fasting level of glucose is ... - Answers 70 to 120 mg/dL
the role of insulin is ... - Answers increase uptake of glucose
What test can you do to measure the glycosolated hemoglobin level? - Answers Hemoglobin A1C
What is the % of a diabetic's A1C
* know for test * - Answers Typically greater than or equal to 6.5% (goal is less than this)