Case Study 16 - Multiple pts with PVD Questions and Answers

Case Study 16 - Multiple pts with PVD Questions and Answers 542613 You have the following pts: Ms. C (38 yo with Raynaud, reports numbness, tingling, cold in wrists and hands b/l) Mr. R (57 yo with chronic peripheral arterial disease, who reports severe pain due to an arterial ulcer on left great toe) Mr. Z (44 yo with Buerger disease who wants to discuss enrolling smoking cessation program) Ms. Q (69 yo with chronic HTN whose BP at end of night shift is 208/96) Mr. S (72 yo in whom an AAA must be ruled out who is reporting severe, worsening back pain) Ms. A (65 yo with peripheral venous disease and calf swelling, scheduled for doppler flow studies this morning) After the change of shift report, you make rounds. List the priority order for assessing your pts. 1. Ms C 2. Mr R 3. Mr Z 4. Ms Q 5. Mr S 6. Ms A 2 You have the following pts: Ms. C (38 yo with Raynaud, reports numbness, tingling, cold in wrists and hands b/l) Mr. R (57 yo with chronic peripheral arterial disease, who reports severe pain due to an arterial ulcer on left great toe) Mr. Z (44 yo with Buerger disease who wants to discuss enrolling smoking cessation program) Ms. Q (69 yo with chronic HTN whose BP at end of night shift is 208/96) Mr. S (72 yo in whom an AAA must be ruled out who is reporting severe, worsening back pain) Ms. A (65 yo with peripheral venous disease and calf swelling, scheduled for doppler flow studies this morning) When Mr S is assessed which technique should be avoided? 1. auscultate abdomen for bruit 2. palpate abdomen to detect a mass 3. observe abdomen for pulsation 4. perform pain assess 3 You have the following pts: Ms. C (38 yo with Raynaud, reports numbness, tingling, cold in wrists and hands b/l) Mr. R (57 yo with chronic peripheral arterial disease, who reports severe pain due to an arterial ulcer on left great toe) Mr. Z (44 yo with Buerger disease who wants to discuss enrolling smoking cessation program) Ms. Q (69 yo with chronic HTN whose BP at end of night shift is 208/96) Mr. S (72 yo in whom an AAA must be ruled out who is reporting severe, worsening back pain) Ms. A (65 yo with peripheral venous disease and calf swelling, scheduled for doppler flow studies this morning) Mr S continues to report severe back pain. On assess, you detect a bruit and notice pulsation in LLQ. What should you do first? 1. measure abdominal girth 2. place pt in high sitting position 3. call HCP 4. pain meds 1 Which action should you delegate to the LPN? 1. insert foley 2. administer morphine sulfate 2 mg IVP 3. place second IV saline lock line 4. measure VS q15mins 123 A CT scan reveals aneurysm 7.5 m in diameter. Which preop care tasks should you delegate to the nursing student under your supervision? (select all) 1. teach about coughing and deep breathing 2. assess all peripheral pulses for postop comparison 3. administer bowel prep mag sulf 4. draw blood for lab for type and screen 5. discuss reasons for surgery 4 Mr S had surgery for AAA. The student nurse reports the pt has no bowel sounds present. What is your best action? 1. check NG tube for kinks 2. notify HCP asap 3. obtain abdominal radiograph stat 4. document finding in chart 1 At 0830, the UAP reports Ms Q with chronic HTN, has BP 198/94. Which is the best task delegation? 1. have LPN give 0900 lasix and enalapril now 2. instruct UAP to get her back into bed asap 3. tell UAP to remeasured BP q15mins 4. send LPN to recheck BP to ensure correct reading 4 A nursing dx for chronic pain has been made for Mr R who has chronic PAD. Which action by the nursing student causes you to intervene? 1. giving narcotic analgesic 45 mins before ulcer dressing change 2. ask pt if he has ever tried progressive muscle relaxation 3. assess pt's response to pain med admin 4. agree to hold pt's colace at pt's request 23 At noon, the LPN goes to CPR training and is replaced by an RN floated from the pacu. Which pts should you assign to the pacu RN? (select all) 1. teaching about how to avoid exacerbation of symptoms for condition 2. needs info about available smoking cessation programs 3. BP still elevated and needs frequent monitoring 4. worried about health care provider that just told her she has a DVT 5. reports back pain getting much worse 1235 You are preparing a teaching plan for Ms C who has Raynaud disease. Which key points should you include? (select all) 1. avoid exposure to cold by wearing warm clothes 2. nifedipine (Procardia) will help decrease and relieve symptoms 3. keep your home at a comfortably warm temp 4. problems you experience are due to vasoconstriction 5. stress reduction techniques can help prevent symptoms 345 A nursing dx of Ineffective peripheral tissue perfusion has been made for Ms C with Raynaud. Which actions can you give to the UAP? (select all) 1. assess peripheral pulse, edema, cap refill, skin temp 2. inspect skin for presence of tissue breakdown and ulcers 3. remind pt to perform active ROM exercises as tolerated 4. reinforce with the pt the need to take in adequate fluids during the day 5. assist the pt to sit at bedside and then transfer to chair 2 Ms A whose calf is swollen from PVD asks why she must have injection of heparin. What's the best response? 1. dissolves clots in legs 2. prevents new clots from forming 3. thins blood and slows down clotting 4. prevents clots from migrating to lungs 1 Ms. A has nursing dx of Risk for Injury from PVD and clots. Which action can you give to UAP? 1. assist pt with morning care and ambulate to bathroom 2. monitor pt's daily INR 3. check pt q4h for bleeding 4. tell pt to call for assistance when getting out of bed