CHAPTER 30

1.

The nurse is taking a health history of a new patient. The patient reports experiencing pain
in his left lower leg and foot when walking. This pain is relieved with rest. The nurse notes
that the left lower leg is slightly edematous and is hairless. When planning this patient's
subsequent care, the nurse should most likely address what health problem?
Ans: Intermittent claudicationFeedback:A muscular, cramp-type pain in the extremities
consistently reproduced with the same degree of exercise or activity and relieved by rest is
experienced by patients with peripheral arterial insufficiency. Referred to as intermittent
claudication, this pain is caused by the inability of the arterial system to provide adequate
blood flow to the tissues in the face of increased demands for nutrients and oxygen during
exercise. The nurse would not suspect the patient has CAD, arterial embolus, or Raynaud's
disease; none of these health problems produce this cluster of signs and symptoms.

2.

While assessing a patient the nurse notes that the patient's ankle-brachial index (ABI) of
the right leg is 0.40. How should the nurse best respond to this assessment finding?
Ans: Implement interventions relevant to arterial narrowing.Feedback:ABI is used to assess
the degree of stenosis of peripheral arteries. An ABI of less than 1.0 indicates possible
claudication of the peripheral arteries. It does not indicate inadequate coronary output.
There is no direct indication for changes in vitamin K intake and OTC medications are not
likely causative.

3.

The nurse is providing care for a patient who has just been diagnosed with peripheral
arterial occlusive disease (PAD). What assessment finding is most consistent with this
diagnosis?
Ans: Unequal peripheral pulses between extremitiesFeedback:PAD assessment may
manifest as unequal pulses between extremities, with the affected leg cooler and paler
than the unaffected leg. Intermittent claudication is far more common than sensations of
numbness and tingling. Clubbing and muscle atrophy are not associated with PAD.

4.

The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns during
the admission assessment that the patient takes oral contraceptives. Consequently, the
nurse's postoperative plan of care should include what intervention?
Ans: Early ambulation and leg exercisesFeedback:Oral contraceptive use increases blood
coagulability; with bed rest, the patient may be at increased risk of developing deep vein
thrombosis. Leg exercises and early ambulation are among the interventions that address
this risk. Assessment of peripheral circulation is important, but Doppler ultrasound may not
be necessary to obtain these data. Dependent positioning increases the risk of venous
thromboembolism (VTE). Contraceptives are not normally discontinued to address the risk
of VTE in the short term.

5.

A nurse is creating an education plan for a patient with venous insufficiency. What measure
should the nurse include in the plan?
Ans: Avoiding tight-fitting socks.Feedback:Measures taken to prevent complications include
avoiding tight-fitting socks and panty girdles; maintaining activities, such as walking,
sleeping with legs elevated, and using pressure stockings. Not included in the teaching plan
for venous insufficiency would be reducing activity, sleeping with legs dependent, and
avoiding pressure stockings. Each of these actions exacerbates venous insufficiency.

6.

The nurse is caring for a patient with a large venous leg ulcer. What intervention should the
nurse implement to promote healing and prevent infection?
Ans: Provide a high-calorie, high-protein diet.Feedback:Wound healing is highly dependent
on adequate nutrition. The diet should be sufficiently high in calories and protein. Antibiotic
ointments are not normally used on the skin surrounding a leg ulcer and occlusive
dressings can exacerbate impaired blood flow. Hydrogen peroxide is not normally used
because it can damage granulation tissue.

7.

The nurse is caring for a patient who returned from the tropics a few weeks ago and who
sought care with signs and symptoms of lymphedema. The nurse's plan of care should
prioritize what nursing diagnosis?
Ans: Risk for infection related to lymphedemaFeedback:Lymphedema, which is caused by

accumulation of lymph in the tissues, constitutes a significant risk for infection. The
patient's body image is likely to be disturbed, and the nurse should address this, but
infection is a more significant threat to the patient's physiological well-being. Lymphedema
is unrelated to ineffective health maintenance and deficient fluid volume is not a significant
risk.
8.

An occupational health nurse is providing an educational event and has been asked by an
administrative worker about the risk of varicose veins. What should the nurse suggest as a
proactive preventative measure for varicose veins?
Ans: Walk for several minutes every hour to promote circulation.Feedback:A proactive
approach to preventing varicose veins would be to walk for several minutes every hour to
promote circulation. Sitting with crossed legs may promote relaxation, but it is
contraindicated for patients with, or at risk for, varicose veins. Elevating the legs only helps
blood passively return to the heart and does not help maintain the competency of the
valves in the veins. Wearing tight ankle socks is contraindicated for patients with, or at risk
for, varicose veins; socks that are below the muscles of the calf do not promote venous
return, the socks simply capture the blood and promote venous stasis.

9.

A patient comes to the walk-in clinic with complaints of pain in his foot following stepping
on a roofing nail 4 days ago. The patient has a visible red streak running up his foot and
ankle. What health problem should the nurse suspect?
Ans: LymphangitisFeedback:Lymphangitis is an acute inflammation of the lymphatic
channels. It arises most commonly from a focus of infection in an extremity. Usually, the
infectious organism is hemolytic streptococcus. The characteristic red streaks that extend
up the arm or the leg from an infected wound outline the course of the lymphatic vessels
as they drain. Cellulitis is caused by bacteria, which cause a generalized edema in the
subcutaneous tissues surrounding the affected area. Local inflammation would not present
with red streaks in the lymphatic channels. Elephantiasis is transmitted by mosquitoes that
carry parasitic worm larvae; the parasites obstruct the lymphatic channels and results in
gross enlargement of the limbs.

10. The triage nurse in the ED is assessing a patient who has presented with complaint of pain
and swelling in her right lower leg. The patient's pain became much worse last night and
appeared along with fever, chills, and sweating. The patient states, "I hit my leg on the car
door 4 or 5 days ago and it has been sore ever since." The patient has a history of chronic
venous insufficiency. What intervention should the nurse anticipate for this patient?
Ans: Antibiotics to treat cellulitisFeedback:Cellulitis is the most common infectious cause of
limb swelling. The signs and symptoms include acute onset of swelling, localized redness,
and pain; it is frequently associated with systemic signs of fever, chills, and sweating. The
patient may be able to identify a trauma that accounts for the source of infection.
Thrombocytopenia is a loss or decrease in platelets and increases a patient's risk of
bleeding; this problem would not cause these symptoms. Arterial insufficiency would
present with ongoing pain related to activity. This patient does not have signs and
symptoms of VTE.
11. A nurse in a long-term care facility is caring for an 83-year-old woman who has a history of
HF and peripheral arterial disease (PAD). At present the patient is unable to stand or
ambulate. The nurse should implement measures to prevent what complication?
Ans: Deep vein thrombosisFeedback:Although the exact cause of venous thrombosis
remains unclear, three factors, known as Virchow's triad, are believed to play a significant
role in its development: stasis of blood (venous stasis), vessel wall injury, and altered blood
coagulation. In this woman's case, she has venous stasis from immobility, vessel wall injury
from PAD, and altered blood coagulation from HF. The cause of aoritis is unknown, but it has
no direct connection to HF, PAD, or mobility issues. The greatest risk factors for thoracic
aortic aneurysm are atherosclerosis and hypertension; there is no direct connection to HF,
PAD, or mobility issues. Raynaud's disease is a disorder that involves spasms of blood
vessels and, again, no direct connection to HF, PAD, or mobility issues.
12. A nurse is admitting a 45-year-old man to the medical unit who has a history of PAD. While
providing his health history, the patient reveals that he smokes about two packs of
cigarettes a day, has a history of alcohol abuse, and does not exercise. What would be the
priority health education for this patient?
Ans: Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or
aggravate PAD.Feedback:Tobacco is powerful vasoconstrictor; its use with PAD is highly

detrimental, and patients are strongly advised to stop using tobacco. Sedentary lifestyle is
also a risk factor, but smoking is likely a more significant risk factor that the nurse should
address. Alcohol use is less likely to cause PAD, although it carries numerous health risks.
13. A nurse has written a plan of care for a man diagnosed with peripheral arterial insufficiency.
One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related
to compromised circulation. What is the most appropriate intervention for this diagnosis?
Ans: Encourage the patient to engage in a moderate amount of exercise.Feedback:The
nursing diagnosis of altered peripheral tissue perfusion related to compromised circulation
requires interventions that focus on improving circulation. Encouraging the patient to
engage in a moderate amount of exercise serves to improve circulation. Elevating his legs
and arms above his heart when resting would be passive and fails to promote circulation.
Encouraging long periods of sitting or standing would further compromise circulation. The
nurse should encourage, not discourage, walking to increase circulation and decrease pain.
14. The nurse is caring for a 72-year-old patient who is in cardiac rehabilitation following heart
surgery. The patient has been walking on a regular basis for about a week and walks for 15
minutes 3 times a day. The patient states that he is having a cramp-like pain in the legs
every time he walks and that the pain gets "better when I rest." The patient's care plan
should address what problem?
Ans: Acute pain related to intermittent claudicationFeedback:Intermittent claudication
presents as a muscular, cramp-type pain in the extremities consistently reproduced with
the same degree of exercise or activity and relieved by rest. Patients with peripheral
arterial insufficiency often complain of intermittent claudication due to a lack of oxygen to
muscle tissue. Venous insufficiency presents as a disorder of venous blood reflux and does
not present with cramp-type pain with exercise. Vasculitis is an inflammation of the blood
vessels and presents with weakness, fever, and fatigue, but does not present with cramptype pain with exercise. The pain associated with VTE does not have this clinical
presentation.
15. A nurse in the rehabilitation unit is caring for an older adult patient who is in cardiac
rehabilitation following an MI. The nurse's plan of care calls for the patient to walk for 10
minutes 3 times a day. The patient questions the relationship between walking and heart
function. How should the nurse best reply?
Ans: "When you walk, the muscles in your legs contract and pump the blood in your veins
back toward your heart, which allows more blood to return to your heart."Feedback:Veins,
unlike arteries, are equipped with valves that allow blood to move against the force of
gravity. The legs have one-way bicuspid valves that prevent blood from seeping backward
as it moves forward by the muscles in our legs pressing on the veins as we walk and
increasing venous return. Leg arteries do constrict when walking, which allows the blood to
move faster and with more pressure on the tissue, but the greater concern is increasing the
flow of venous blood to the heart. Walking increases, not decreases, the heart' pumping
ability, which increases heart rate and blood pressure and the hearts ability to manage
stress. Walking does help the heart adjust to new arteries and may enhance self-esteem,
but the patient had an MIthere are no "new arteries."
16. The nurse is caring for a patient who is admitted to the medical unit for the treatment of a
venous ulcer in the area of her lateral malleolus that has been unresponsive to treatment.
What is the nurse most likely to find during an assessment of this patient's wound?
Ans: Heavy exudateFeedback:Venous ulcerations in the area of the medial or lateral
malleolus (gaiter area) are typically large, superficial, and highly exudative. Venous
hypertension causes extravasation of blood, which discolors the area of the wound bed.
Bleeding is not normally present.
17. The nurse is preparing to administer warfarin (Coumadin) to a client with deep vein
thrombophlebitis (DVT). Which laboratory value would most clearly indicate that the
patient's warfarin is at therapeutic levels?
Ans: International normalized ratio (INR) between 2 and 3Feedback:The INR is most often
used to determine if warfarin is at a therapeutic level; an INR of 2 to 3 is considered
therapeutic. Warfarin is also considered to be at therapeutic levels when the client's PT is
1.5 to 2 times the control. Higher values indicate increased risk of bleeding and
hemorrhage, whereas lower values indicate increased risk of blood clot formation. Heparin,
not warfarin, prolongs PTT. Hematocrit does not provide information on the effectiveness of
warfarin; however, a falling hematocrit in a client taking warfarin may be a sign of
hemorrhage.

18. The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain
whenever she walks several blocks. The patient has type 1 diabetes and has smoked a
pack of cigarettes every day for the past 40 years. The physician diagnoses intermittent
claudication. The nurse should provide what instruction about long-term care to the client?
Ans: "Be sure to practice meticulous foot care."Feedback:The patient with peripheral
vascular disease or diabetes should receive education or reinforcement about skin and foot
care. Intermittent claudication and other chronic peripheral vascular diseases reduce
oxygenation to the feet, making them susceptible to injury and poor healing; therefore,
meticulous foot care is essential. The patient should stop smokingnot just cut down
because nicotine is a vasoconstrictor. Daily walking benefits the patient with intermittent
claudication. Increased protein intake will not alleviate the patient's symptoms.
19. A patient who has undergone a femoral to popliteal bypass graft surgery returns to the
surgical unit. Which assessments should the nurse perform during the first postoperative
day?
Ans: Assess pulse of affected extremity every 15 minutes at first.Feedback:The primary
objective in the postoperative period is to maintain adequate circulation through the
arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and
sensory and motor function of the affected extremity are checked and compared with those
of the other extremity; these values are recorded initially every 15 minutes and then at
progressively longer intervals if the patient's status remains stable. Doppler evaluations
should be performed every 2 hours. Pain is regularly assessed, but palpation is not the
preferred method of performing this assessment. Compartment syndrome results from the
placement of a cast, not from vascular surgery.
20. You are caring for a patient who is diagnosed with Raynaud's phenomenon. The nurse
should plan interventions to address what nursing diagnosis?
Ans: Ineffective tissue perfusionFeedback:Raynaud's phenomenon is a form of intermittent
arteriolar vasoconstriction resulting in inadequate tissue perfusion. This results in coldness,
pain, and pallor of the fingertips or toes. Pain is typically intermittent and acute, not
chronic, and skin integrity is rarely at risk. In most cases, the patient is not at a high risk for
injury.
21. A patient presents to the clinic complaining of the inability to grasp objects with her right
hand. The patient's right arm is cool and has a difference in blood pressure of more than 20
mm Hg compared with her left arm. The nurse should expect that the primary care provider
may diagnose the woman with what health problem?
Ans: Upper extremity arterial occlusive diseaseFeedback:The patient with upper extremity
arterial occlusive disease typically complains of arm fatigue and pain with exercise
(forearm claudication) and inability to hold or grasp objects (e.g., combing hair, placing
objects on shelves above the head) and, occasionally, difficulty driving. Assessment
findings include coolness and pallor of the affected extremity, decreased capillary refill, and
a difference in arm blood pressures of more than 20 mm Hg. These symptoms are not
closely associated with Raynaud's or lymphedema. The upper extremities are rare sites for
VTE.
22. A nurse working in a long-term care facility is performing the admission assessment of a
newly admitted, 85-year-old resident. During inspection of the resident's feet, the nurse
notes that she appears to have early evidence of gangrene on one of her great toes. The
nurse knows that gangrene in the elderly is often the first sign of what?
Ans: PADFeedback:In elderly people, symptoms of PAD may be more pronounced than in
younger people. In elderly patients who are inactive, gangrene may be the first sign of
disease. Venous insufficiency does not normally manifest with gangrene. Similarly, VTE and
Raynaud's phenomenon do not cause the ischemia that underlies gangrene.
23. The prevention of VTE is an important part of the nursing care of high-risk patients. When
providing patient teaching for these high-risk patients, the nurse should advise lifestyle
changes, including which of the following? Select all that apply.
Ans: Weight loss, Regular exercise, Smoking cessationFeedback:Patients at risk for VTE
should be advised to make lifestyle changes, as appropriate, which may include weight
loss, smoking cessation, and regular exercise. Increased protein intake and
supplementation with vitamin D and calcium do not address the main risk factors for VTE.
24. The nurse is caring for an acutely ill patient who is on anticoagulant therapy. The patient
has a comorbidity of renal insufficiency. How will this patient's renal status affect heparin

therapy?
Ans: Lower doses of heparin are required for this patient.Feedback:If renal insufficiency
exists, lower doses of heparin are required. Coumadin cannot be safely and effectively used
as a substitute and there is no contraindication for IV administration.
25. The nurse is assessing a woman who is pregnant at 27 weeks' gestation. The patient is
concerned about the recent emergence of varicose veins on the backs of her calves. What
is the nurse's best response?
Ans: Teach the patient that circulatory changes during pregnancy frequently cause varicose
veins.Feedback:Pregnancy may cause varicosities because of hormonal effects related to
decreased venous outflow, increased pressure by the gravid uterus, and increased blood
volume. In most cases, no intervention or referral is necessary. This finding is not an
indication for ABI assessment and increased activity will not likely resolve the problem.
26. Graduated compression stockings have been prescribed to treat a patient's venous
insufficiency. What education should the nurse prioritize when introducing this intervention
to the patient?
Ans: The importance of ensuring the stockings are applied evenly with no pressure points
Feedback:Any type of stocking can inadvertently become a tourniquet if applied incorrectly
(i.e., rolled tightly at the top). In such instances, the stockings produce rather than prevent
stasis. For ambulatory patients, graduated compression stockings are removed at night and
reapplied before the legs are lowered from the bed to the floor in the morning. They are
used daily, not on alternating days. Anticoagulants are not always indicated in patients who
are using compression stockings.
27. The nurse caring for a patient with a leg ulcer has finished assessing the patient and is
developing a problem list prior to writing a plan of care. What major nursing diagnosis
might the care plan include?
Ans: Imbalanced nutrition: less than body requirementsFeedback:Major nursing diagnoses
for the patient with leg ulcers may include imbalanced nutrition: less than body
requirements, related to increased need for nutrients that promote wound healing. Risk for
disuse syndrome is a state in which an individual is at risk for deterioration of body systems
owing to prescribed or unavoidable musculoskeletal inactivity. A leg ulcer will affect
activity, but rarely to this degree. Leg ulcers are not necessarily a consequence of
ineffective health maintenance or sedentary lifestyle.
28. How should the nurse best position a patient who has leg ulcers that are venous in origin?
Ans: Elevate the patient's lower extremities.Feedback:Positioning of the legs depends on
whether the ulcer is of arterial or venous origin. With venous insufficiency, dependent
edema can be avoided by elevating the lower extremities. Dangling the patient's legs and
applying pillows may further compromise venous return.
29. A patient with advanced venous insufficiency is confined following orthopedic surgery. How
can the nurse best prevent skin breakdown in the patient's lower extremities?
Ans: Ensure that the patient's heels are protected and supported.Feedback:If the patient is
on bed rest, it is important to relieve pressure on the heels to prevent pressure ulcerations,
since the heels are among the most vulnerable body regions. Monitoring blood work does
not directly prevent skin breakdown, even though albumin is related to wound healing.
Massage is not normally indicated and may exacerbate skin breakdown. Passive range- ofmotion exercises do not directly reduce the risk of skin breakdown.
30. The nurse has performed a thorough nursing assessment of the care of a patient with
chronic leg ulcers. The nurse's assessment should include which of the following
components? Select all that apply.
Ans: Location and type of pain, Bilateral comparison of peripheral pulses, Comparison of
temperature in the patient's legs, Identification of mobility limitationsFeedback:A careful
nursing history and assessment are important. The extent and type of pain are carefully
assessed, as are the appearance and temperature of the skin of both legs. The quality of all
peripheral pulses is assessed, and the pulses in both legs are compared. Any limitation of
mobility and activity that results from vascular insufficiency is identified. Not likely is there
any direct indication for assessment of apical heart rate, although peripheral pulses must
be assessed.

31. A nurse on a medical unit is caring for a patient who has been diagnosed with lymphangitis.
When reviewing this patient's medication administration record, the nurse should anticipate
which of the following?
Ans: An antibioticFeedback:Lymphangitis is an acute inflammation of the lymphatic
channels caused by an infectious process. Antibiotics are always a component of
treatment. Diuretics are of nominal use. Anticoagulants and antiplatelet aggregators are
not indicated in this form of infection.
32. A postsurgical patient has illuminated her call light to inform the nurse of a sudden onset of
lower leg pain. On inspection, the nurse observes that the patient's left leg is visibly
swollen and reddened. What is the nurse's most appropriate action?
Ans: Inform the physician that the patient has signs and symptoms of VTE.Feedback:VTE
requires prompt medical follow-up. Heparin will not dissolve an established clot. Massaging
the patient's leg and mobilizing the patient would be contraindicated because they would
dislodge the clot, possibly resulting in a pulmonary embolism.
33. A nurse is closely monitoring a patient who has recently been diagnosed with an abdominal
aortic aneurysm. What assessment finding would signal an impending rupture of the
patient's aneurysm?
Ans: Sudden onset of severe back or abdominal painFeedback:Signs of impending rupture
include severe back or abdominal pain, which may be persistent or intermittent. Impending
rupture is not typically signaled by increased blood pressure, bradycardia, cessation of
pulsing, or hemoptysis.
34. A nurse is reviewing the physiological factors that affect a patient's cardiovascular health
and tissue oxygenation. What is the systemic arteriovenous oxygen difference?
Ans: The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval
bloodFeedback:The average amount of oxygen removed collectively by all of the body
tissues is about 25%. This means that the blood in the vena cava contains about 25% less
oxygen than aortic blood. This is known as the systemic arteriovenous oxygen difference.
The other answers do not apply.
35. The nurse is evaluating a patient's diagnosis of arterial insufficiency with reference to the
adequacy of the patient's blood flow. On what physiological variables does adequate blood
flow depend? Select all that apply.
Ans: Efficiency of heart as a pump, Adequacy of circulating blood volume, Patency and
responsiveness of the blood vesselsFeedback:Adequate blood flow depends on the
efficiency of the heart as a pump, the patency and responsiveness of the blood vessels,
and the adequacy of circulating blood volume. Adequacy of blood flow does not primarily
depend on the size of red cells or their ratio to the number of platelets.
36. A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the
pulse in the patient's left foot. How should the nurse proceed with assessment?
Ans: Use Doppler ultrasound to identify the pulses.Feedback:When pulses cannot be
reliably palpated, a hand-held continuous wave (CW) Doppler ultrasound device may be
used to hear (insonate) the blood flow in vessels. CT is not normally warranted and the
application of a tourniquet poses health risks and will not aid assessment. Elevating the
extremity would make palpation more difficult.
37. A medical nurse has admitted four patients over the course of a 12-hour shift. For which
patient would assessment of ankle-brachial index (ABI) be most clearly warranted?
Ans: A patient with poorly controlled type 1 diabetes who is a smokerFeedback:Nurses
should perform a baseline ABI on any patient with decreased pulses or any patient 50 years
of age or older with a history of diabetes or smoking. The other answers do not apply.
38. An older adult patient has been treated for a venous ulcer and a plan is in place to prevent
the occurrence of future ulcers. What should the nurse include in this plan?
Ans: A high-protein diet that is rich in vitaminsFeedback:A diet that is high in protein,
vitamins C and A, iron, and zinc is encouraged to promote healing and prevent future
ulcers. Prophylactic antibiotics and saline compresses are not used to prevent ulcers.
Oxygen supplementation does not prevent ulcer formation.

39. A 79-year-old man is admitted to the medical unit with digital gangrene. The man states
that his problems first began when he stubbed his toe going to the bathroom in the dark. In
addition to this trauma, the nurse should suspect that the patient has a history of what
health problem?
Ans: Arterial insufficiencyFeedback:Arterial insufficiency may result in gangrene of the toe
(digital gangrene), which usually is caused by trauma. The toe is stubbed and then turns
black. Raynaud's, CAD and varicose veins are not the usual causes of digital gangrene in
the elderly.
40. When assessing venous disease in a patient's lower extremities, the nurse knows that what
test will most likely be ordered?
Ans: Duplex ultrasonographyFeedback:Duplex ultrasound may be used to determine the
level and extent of venous disease as well as its chronicity. Radiographs (x-rays), PET
scanning, and echocardiography are never used for this purpose as they do not allow
visualization of blood flow.