Question 1 of 6
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Which instruction would the nurse give to the home health aide who is assigned to assist a patient who has varicose veins?
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- Use saline or mild soap and warm water to clean around the varicosities.Saline, mild soap, and lanolin-type lotion are used for venous stasis ulcerations.
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- Massage the legs gently after bathing and apply lanolin-type lotion.Massaging the legs is generally not recommended.
- Correct
- Encourage and assist the patient to ambulate as much as possible.Varicose veins are enlarged, tortuous veins engorged with pooled blood. Walking is encouraged because the muscle contraction helps the blood to flow back toward the heart.
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- Measure the patient’s legs and calves to ensure the fit of elastic stockings.Determining the correct size of elastic stockings is essential, and the nurse would measure the legs and calves; this task should not be delegated to the aide.
Question 2 of 6
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The nurse is caring for a patient with new-onset dyspnea. The nurse suspects a pulmonary embolism. Which is the priority action of the nurse?
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- Call the patient’s family.The nurse should notify the provider first before calling the patient’s family.
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- Administer intravenous (IV) heparin.Though IV heparin may be indicated, there is no diagnosis or order, so this is not correct.
- Correct
- Place patient in high Fowler position.The nurse should place a patient with suspected pulmonary embolism in high Fowler position to improve respiratory status.
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- Leave the patient and find assistance.The nurse should stay with a patient with suspected pulmonary embolism.
Question 3 of 6
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A patient with deep vein thrombosis (DVT) is prescribed warfarin sodium. Which patient statement indicates understanding of the medication?
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- “Warfarin will dissolve the clot that is in my leg.”Warfarin is an anticoagulant, not a thrombolytic, so it will not dissolve existing clots.
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- “This drug will be given to me in my intravenous catheter.”Warfarin is an oral medication and is not administered intravenously.
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- “This medication will be injected into my abdomen.”Warfarin is an oral medication and is not administered subcutaneously.
- Correct
- “I will take this medication for several months at home.”Warfarin is an oral anticoagulant that is taken for several months by the patient at home after discharge.
Question 4 of 6
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Upon assessment of a patient with deep vein thrombosis (DVT), which clinical manifestation would the nurse expect to find? Select all that apply. One, some, or all responses may be correct.
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- Calf painCalf pain or tenderness is a common finding with DVT.
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- HypothermiaFever, not hypothermia, is a common finding with DVT.
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- Redness over a veinRedness and warmth over a vein is a common finding with DVT.
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- Mild edema of lower extremitySevere, pitting edema is a common finding with DVT.
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- One lower extremity slightly largerOne lower extremity that is slightly larger is a common sign of DVT.
Question 5 of 6
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Which teaching point is important to include for a patient taking Butcher’s broom for treatment of varicose veins?
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- This herb can also help with high blood pressure.Gotu kola can be helpful for treating hypertension in addition to varicose veins.
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- This herb often causes issues with constipation.Bilberry can cause symptoms of constipation.
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- This herb should not be taken with diabetic medications.Horse chestnut should not be taken with hypoglycemic medications.
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- This herb should not be taken by a patient with an enlarged prostate.Butcher’s broom should not be taken by patients with prostatic hypertrophy.
Question 6 of 6
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Which patient statement indicates understanding of the treatment for venous stasis ulcers?
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- “I need to change my dressings every 2 to 3 days.”Patients with venous stasis ulcers should change their dressing every 2 to 3 days to prevent infection.
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- “I will avoid wearing compression stockings on that leg.”Compression stockings should still be worn on legs with venous stasis ulcers to improve blood flow and circulation.
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- “They should just go away on their own without treatment.”Venous stasis ulcers need to be treated and do not go away on their own. They can take a long time to heal effectively, even with treatment.
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- “There is no need to notify my provider when I notice a new ulcer.”Patient who notice a new ulcer need to notify their health care provider immediately, even if it is minor.
