Complex Care Study test in depth
Examination and 100% correctly verified
Solutions Latest version 2024/2025
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 - correct answer a. Duplex ultrasound
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.
Assessment of a patient's peripheral IV site reveals that phlebitis has developed 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. - correct answer a. Remove the patient's IV
catheter.
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 postoperative patient asks the nurse why the physician ordered daily administration of
enoxaparin (Lovenox). Which reply by the nurse is most appropriate?
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." - correct answer c. "This medication will
help prevent blood clots from forming in your legs until your level of activity, such as walking,
returns to normal."
Enoxaparin is an anticoagulant that is used to prevent dvts postoperatively. All other options do
not describe the action or purpose of enoxaparin.
Which assessment findings of the left lower extremity will the nurse identify as consistent with
arterial occlusion (select all that apply.)?
A. Edematous
B. Cold and mottled
C. Complaints of paresthesia
D. Pulse not palpable with Doppler
E. Capillary refill less than three seconds
F. Erythema and warmer than right lower extremity - correct answer b. Cold and mottled
C. Complaints of paresthesia
D. Pulse not palpable with Doppler
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.
A 62-yr-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral
artery disease (PAD). The patient is a smoker with a history of gout. To prevent complications,
which factor is priority in patient teaching?
A. Gender
B. Smoking
C. Ethnicity
,D. Comorbidities - correct answer b. Smoking
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 mellitus and hyperuricemia are also risk factors. Being male or
Hispanic are not risk factors for PAD.
A 32-yr-old woman is prescribed diltiazem (Cardizem) for Raynaud's phenomenon. To evaluate
the effectiveness of the medication, which assessment will the nurse perform?
A. Improved skin turgor
B. Decreased cardiac rate
C. Improved finger perfusion
D. Decreased mean arterial pressure - correct answer c. Improved finger perfusion
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 patient has chronic venous insufficiency and a venous ulcer. The unlicensed assistive
personnel (UAP) decides to apply compression stockings because that is what patients 'always'
have ordered. Which assessment finding would indicate the application of compression
stockings could harm the patient?
A. Rest pain
B. High blood pressure
C. Elevated blood sugar
D. Dry, itchy, flaky skin - correct answer a. Rest pain
Rest pain occurs as peripheral artery disease (PAD) progresses and involves multiple arterial
segments. Compression stockings should not be used on patients with PAD. Elevated blood
glucose, possibly indicating uncontrolled diabetes mellitus, and hypertension may or may not
indicate arterial problems. Dry, itchy, flaky skin indicates venous insufficiency. The RN should be
, the one to obtain the order and instruct the UAP to apply compression stockings if they are
ordered.
The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin
(Lanoxin) 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 - correct answer c. Cerebral or pulmonary
emboli
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.
The nurse is reviewing the laboratory test results for a 68-yr-old patient whose warfarin
(Coumadin) therapy was terminated during the preoperative period. 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 physician to request an increased dose of warfarin. - correct answer b. Administer
the daily dose of warfarin.
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.
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?
Examination and 100% correctly verified
Solutions Latest version 2024/2025
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 - correct answer a. Duplex ultrasound
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.
Assessment of a patient's peripheral IV site reveals that phlebitis has developed 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. - correct answer a. Remove the patient's IV
catheter.
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 postoperative patient asks the nurse why the physician ordered daily administration of
enoxaparin (Lovenox). Which reply by the nurse is most appropriate?
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." - correct answer c. "This medication will
help prevent blood clots from forming in your legs until your level of activity, such as walking,
returns to normal."
Enoxaparin is an anticoagulant that is used to prevent dvts postoperatively. All other options do
not describe the action or purpose of enoxaparin.
Which assessment findings of the left lower extremity will the nurse identify as consistent with
arterial occlusion (select all that apply.)?
A. Edematous
B. Cold and mottled
C. Complaints of paresthesia
D. Pulse not palpable with Doppler
E. Capillary refill less than three seconds
F. Erythema and warmer than right lower extremity - correct answer b. Cold and mottled
C. Complaints of paresthesia
D. Pulse not palpable with Doppler
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.
A 62-yr-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral
artery disease (PAD). The patient is a smoker with a history of gout. To prevent complications,
which factor is priority in patient teaching?
A. Gender
B. Smoking
C. Ethnicity
,D. Comorbidities - correct answer b. Smoking
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 mellitus and hyperuricemia are also risk factors. Being male or
Hispanic are not risk factors for PAD.
A 32-yr-old woman is prescribed diltiazem (Cardizem) for Raynaud's phenomenon. To evaluate
the effectiveness of the medication, which assessment will the nurse perform?
A. Improved skin turgor
B. Decreased cardiac rate
C. Improved finger perfusion
D. Decreased mean arterial pressure - correct answer c. Improved finger perfusion
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 patient has chronic venous insufficiency and a venous ulcer. The unlicensed assistive
personnel (UAP) decides to apply compression stockings because that is what patients 'always'
have ordered. Which assessment finding would indicate the application of compression
stockings could harm the patient?
A. Rest pain
B. High blood pressure
C. Elevated blood sugar
D. Dry, itchy, flaky skin - correct answer a. Rest pain
Rest pain occurs as peripheral artery disease (PAD) progresses and involves multiple arterial
segments. Compression stockings should not be used on patients with PAD. Elevated blood
glucose, possibly indicating uncontrolled diabetes mellitus, and hypertension may or may not
indicate arterial problems. Dry, itchy, flaky skin indicates venous insufficiency. The RN should be
, the one to obtain the order and instruct the UAP to apply compression stockings if they are
ordered.
The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin
(Lanoxin) 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 - correct answer c. Cerebral or pulmonary
emboli
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.
The nurse is reviewing the laboratory test results for a 68-yr-old patient whose warfarin
(Coumadin) therapy was terminated during the preoperative period. 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 physician to request an increased dose of warfarin. - correct answer b. Administer
the daily dose of warfarin.
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.
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?
