DVT/PVD/PE/HTN/ED-TestBank

The nurse instructs a client about the medication nifedipine (Procardia) for hypertension. Which client statement indicates that additional teaching is needed? A) "This medication will cause my ankles to swell, which is normal." B) "I need to drink 6-8 glasses of water each day." C) "I will call my doctor if I gain weight or become short of breath." D) "I need to eat foods high in fiber when taking this medication."

A) "This medication will cause my ankles to swell, which is normal." Swelling in the feet or ankles when taking this medication should be reported to the healthcare provider. This medication can cause constipation, so drinking 6-8 glasses of water each day and increasing fiber in the diet are appropriate interventions cited by the client. The client should notify the healthcare provider with weight gain or shortness of breath.

A client reports morning headache that extends into the neck and goes away as the day wears on. What should the nurse suspect this client is describing? A) A symptom of hypertension B) A sinus headache C) A migraine headache D) Spinal stenosis

A) A symptom of hypertension When symptoms of hypertension do appear, they are usually vague. Headache, generally in the back of the head and neck, may be present on awakening, subsiding during the day. The client is not describing a migraine or sinus headache. There is not enough information to determine whether the client has spinal stenosis.

A client is concerned about becoming impotent because of the inability to sustain an erection and a history of a sexually transmitted infection as a young adult. What is the nurse's best response to this client's concerns? A) An occasional incident like this is normal and common, and there is no reason to be concerned. B) Sexually transmitted infections may result in sexual problems in adults. C) Erectile dysfunction is the correct term for the inability to achieve or sustain an erection. D) The medical diagnosis of erectile dysfunction is not made until the man has erection difficulties in 25% or more of his interactions.

A) An occasional incident like this is normal and common, and there is no reason to be concerned. This client is concerned about his masculinity and sexual abilities. The correct answer at this point is to tell him that it is common and normal for men to experience occasional erectile difficulties. The other options are also true, but they do not serve to alleviate the client's concerns. If the client continues to have difficulties achieving or sustaining an erection, further investigation should take place. Simply correcting the client's use of medical terminology does not address his concerns.

The nurse is providing discharge instructions to a postpartum client recovering from deep venous thrombosis. What should these instructions include? Select all that apply. A) Avoid crossing the legs. B) Avoid long car trips. C) Avoid prolonged standing or sitting. D) Take frequent walks. E) Take a daily aspirin dose of 650 mg.

A) Avoid crossing the legs. C) Avoid prolonged standing or sitting. D) Take frequent walks. The client should be instructed to avoid crossing the legs because it increases pressure on the veins of the lower extremities. The client should be instructed also to avoid prolonged standing or sitting, which contributes to venous stasis. The client should also be instructed to take frequent walks to promote venous return. The client should not be instructed to take a daily aspirin, because it will increase anticoagulant activity and could interact with other medication prescribed for the treatment of the deep venous thrombosis. The client does not need to be instructed to avoid long car trips but rather to take frequent breaks during long car trips.

3) An older client is diagnosed with cardiomyopathy and a cardiac dysrhythmia. What would the nurse expect to be indicated for this client? A) Beta blocker B) Digoxin C) Nitrate medications D) Fluids

A) Beta blocker Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and antiarrhythmics. Nitrates should be avoided because they increase blood pressure. Digoxin should be avoided because it increases the force of contractions. The client should be on a sodium and fluid restriction and not be encouraged to drink fluids.

The nurse is concerned that a client admitted for a total hip replacement is at risk for thrombus formation. What assessment information caused the nurse to come to this conclusion? A) Body mass index (BMI) 35.8 B) Former cigarette smoker C) Blood pressure 132/88 mmHg D) Age 45 years

A) Body mass index (BMI) 35.8 Risk factors for the development of thrombus formation that could lead to a pulmonary embolism include obesity, orthopedic surgery, myocardial infarction, heart failure, and advancing age. The BMI of 35.8 falls into the category of obese, which would increase the client's risk of developing a thrombus and possible pulmonary embolism. The client's age, status as a former smoker, and blood pressure would not have as significant an impact on the development of a thrombus as the client's weight.

A client diagnosed with peripheral vascular disease is obese, has a 30-year history of cigarette smoking, and works as a contractor. What should the nurse instruct the client about the diagnosis? A) Nicotine is a vasoconstrictor. B) Obesity is a factor in cardiovascular disease but not peripheral vascular disease. C) Nicotine primarily affects coronary arteries and the lungs. D) The client's occupation is a major risk factor.

A) Nicotine is a vasoconstrictor. The vasoconstrictive properties of nicotine will worsen the client's peripheral vascular disease (PVD) by further decreasing peripheral blood flow. One of the most important parts of treatment is the cessation of cigarette smoking. The client's occupation is not a risk factor related to PVD. Obesity is a risk factor for both cardiovascular as well as PVD; however, the nurse should focus on smoking cessation as a first priority with this client.

A nurse is performing an assessment on a client diagnosed with aortic stenosis. The nurse will hear the client's murmur best at: A) Right sternal border, second intercostal space. B) Left sternal border, second intercostal space. C) Right sternal border, third intercostal space. D) Left sternal border, third to fifth intercostal space.

A) Right sternal border, second intercostal space. The murmur associated with aortic stenosis is auscultated on the right sternal border, second intercostal space.

The nurse is caring for a client with erectile dysfunction (ED). Which medication should the nurse anticipate being prescribed for this client? Select all that apply. A) Sildenafil (Viagra) B) Methylphenidate (Ritalin) C) Vardenafil (Levitra) D) Buspirone (BuSpar) E) Tadalafil (Cialis)

A) Sildenafil (Viagra) C) Vardenafil (Levitra) E) Tadalafil (Cialis) Sildenafil (Viagra) works to relax the smooth muscles in the penis, allowing increased blood flow to the penis resulting in an erection. Vardenafil (Levitra) works to relax the smooth muscles in the penis, allowing increased blood flow to the penis resulting in an erection. Tadalafil (Cialis) works to relax the smooth muscles in the penis, allowing increased blood flow to the penis resulting in an erection. Buspirone (Buspar) is an antianxiety agent and is not effective for erectile dysfunction (ED). Methylphenidate (Ritalin) is a mild central nervous system stimulant and is not effective for ED.

A client's stroke volume (SV) is 85mL/beat and the heart rate (HR) is 71 beats per minute. What is the client's cardiac output (CO) rounded to the nearest whole number?

Answer: 6 Liters (L) Explanation: CO = SV × HR 85mL = 0.085 L CO = 0.085 × 71 = 6.035 = 6L

During a health history, the nurse learns that a client has a recent onset of impotence. Which question will help identify a potential cause of this manifestation? A) "Does this occur often?" B) "For what diseases and disorders have you been treated?" C) "Are you on any medications?" D) "How does your partner feel about this problem?"

B) "For what diseases and disorders have you been treated?" A client's health history can provide clues to the underlying cause of impotence. The question "for what diseases and disorders have you been treated" would provide the nurse with information as to possible causes for the recent onset of the disorder. Asking the client if the impotence occurs often will not help identify the cause of the problem. Asking the client how the partner feels about the problem also will not help identify a possible cause. The question "are you on any medication?" would be beneficial to ask; however, it should be an open-ended question and not a closed-ended question as identified. The nurse should ask the client to "list any medications" instead of asking "are you on any medication?" which could be answered with a yes or no.

The nurse teaches a client about lifestyle modifications to help manage hypertension. Which client statement indicates teaching has been effective? A) "I won't be able to run in marathons anymore." B) "I know I need to give up my cigarettes and alcohol." C) "I need to get started on my medications right away." D) "My father had hypertension, did nothing, and lived to be 90 years old.

B) "I know I need to give up my cigarettes and alcohol." Limiting intake of alcohol and discontinuing tobacco products are important nonpharmacological methods for controlling hypertension. Implementing lifestyle modifications may eliminate the need for pharmacotherapy, so the client may not have to take medication right away. Increasing physical activity is an important lifestyle modification for controlling hypertension. The fact that the client's father had hypertension and lived to be 90 years old does not mean that the client will have the same experience; the client is in denial.

A nurse is caring for a client who is prescribed a selective phosphodiesterase type 5 inhibitor for the treatment of erectile dysfunction. The nurse should include which statement when educating the client regarding this medication? A) "You should take this medication about 30 minutes before sexual activity." B) "The action of this medication will last up to 36 hours." C) "This medication will enhance erections with or without sexual stimulation." D) "This medication should not be taken more than twice daily."

B) "The action of this medication will last up to 36 hours." Sildenafil citrate (Viagra), vardenafil hydrochloride (Levitra), tadalafil (Cialis), and avanafil (Stendra) are all selective phosphodiesterase type 5 inhibitors used in the treatment of erectile dysfunction. The nurse should tell the client that the action of this medication will last up to 36 hours. The client should take the medication an hour prior to sexual activity, not 30 minutes. This medication will enhance erections only with sexual stimulation and should not be taken more than once daily.

A client receiving heparin therapy for deep venous thrombosis complains of severe chest pain and shortness of breath. Suspecting a pulmonary embolism, what action should the nurse perform first? A) Assess pulse, respirations, and blood pressure. B) Apply oxygen and elevate the head of the bed. C) Reassure the client and notify family members. D) Increase the rate of heparin infusion.

B) Apply oxygen and elevate the head of the bed. Applying oxygen and elevating the head of the bed will promote ventilation and gas exchange in those alveoli that are well perfused, helping to maintain tissue oxygenation. Increasing the rate of heparin infusion cannot be done by the nurse without an order from a healthcare provider. Reassuring the client and notifying family members are not priorities, although these measures can decrease the client's anxiety; the priority is to begin oxygen therapy and elevate the head of the bed to increase oxygenation to the tissues. Assessing pulse, respiration, and blood pressure will be performed following the initiation of oxygen therapy and bed elevation.

An older client receiving medication for hypertension had a recent fall at home. What should the nurse include in this client's plan of care? A) Monitor serum sodium levels. B) Assess postural blood pressures. C) Monitor serum creatinine levels. D) Monitor blood pressure every 2 hours.

B) Assess postural blood pressures. Baroreceptors are less efficient with aging. Therefore, orthostatic hypotension is more likely to occur. Also, clients treated for hypertension could have an increase in sensitivity to the medications. Postural blood pressure assessment allows the nurse to prevent orthostatic hypotension and falls. Every 2 hours is too frequent for assessments of a noncritical client. Sodium intake and creatinine levels assess renal function.

A nurse is caring for a client with venous stasis whose lower extremities have a brown pigmentation appearance. Which is this pigmentation appearance best attributed to? A) The necrosis of subcutaneous fat due to tissue hypoxia B) Breakdown of red blood cells in the congested tissues C) The inflammatory and immune response from congested circulation D) Skin atrophy caused by lack of circulation

B) Breakdown of red blood cells in the congested tissues Breakdown of red blood cells in the congested tissues causes brown skin pigmentation. While the other choices may occur with PVD, they are not responsible for the cause of brown pigmentation to the skin.

6) An elderly female client complains of fatigue, nausea, intermittent chest discomfort, and not sleeping well. What should the nurse suspect this client is experiencing? A) Pancreatic disease B) Cardiac disease C) Normal changes of aging D) Signs of anemia

B) Cardiac disease B) Many elderly women complain of vague symptoms when having a myocardial infarction including fatigue, epigastric pain, and sleep disturbances. Pancreatic disease would present pain in the abdominal region. These symptoms are not considered normal changes of aging. Anemia would present with fatigue but not with nausea or chest discomfort.

7) A client is prescribed metoprolol for a heart disorder. What should the nurse teach the client about this medication? A) Expect a rapid heart rate. B) Change positions slowly. C) Reduce protein intake. D) Increase fluids.

B) Change positions slowly. Metoprolol is a beta blocker. The client should be instructed to use care when ambulating and to change positions slowly since this medication causes orthostatic hypotension. This medication does not cause a rapid heart rate. The client should not be instructed to increase fluids. Protein restriction is not indicated with this medication.

A client is admitted to the hospital in order to have surgical intervention due to peripheral vascular disease (PVD). Which procedure is the likely intervention? A) Stent placement B) Endarterectomy C) Percutaneous transluminal angioplasty D) Atherectomy

B) Endarterectomy Surgical intervention for PVD includes endarterectomy and bypass grafts. All other choices are non-surgical interventions for PVD.

A nurse is caring for a pregnant client who is hypertensive. What additional symptom likely indicates this client has early preeclampsia? A) Persistent headache B) Excessive protein in the urine C) Right-sided abdominal pain D) Severe epigastric pain

B) Excessive protein in the urine Early signs of preeclampsia include high blood pressure and evidence of protein in the urine. Later symptoms include persistent headache and right-sided abdominal pain. Severe epigastric pain is a symptom of HELLP syndrome.

A client has a nighttime cough related to taking enalapril (Vasotec). What is the best nursing intervention to promote rest in this client? A) Have the client sit up at an 80° angle in a comfortable chair at night. B) Have the client sleep on 2 or 3 pillows at night. C) Contact the physician for an order for a cough-suppressant medication. D) Contact the physician for an order for a sedative-hypnotic medication.

B) Have the client sleep on 2 or 3 pillows at night. The client should sleep with the head elevated if a cough becomes troublesome when in supine position. A cough induced by an angiotensin-converting enzyme inhibitor will not be relieved by cough medication. Sitting up at an 80° angle would be effective but would be too uncomfortable for the client. A sedative-hypnotic medication would put the client to sleep, but it does nothing to address the client's cough.

A client has a blood pressure of 142/92. The nurse recognizes this as: A) Normal. B) Hypertension Stage I. C) Prehypertension. D) Hypertension Stage II.

B) Hypertension Stage I. Blood pressure values in the adult are classified as either normal (<120/<80 mmHg), prehypertension (120-139/80-89), hypertension stage I (140-159/90-99), or hypertension stage II (> or =160/> or =100).

The nurse is planning care for a client with erectile dysfunction. What should the nurse include in this client's plan of care? Select all that apply. A) Names of psychologists with experience in treating the disorder B) Information on medications for treatment C) Types of devices and surgeries available to help with the disorder D) Reason for disorder as being side effect of prescribed medication E) Information on exact cause

B) Information on medications for treatment C) Types of devices and surgeries available to help with the disorder When planning the care of a client with erectile dysfunction, the nurse should include information on medications for treatment and types of devices and surgeries available to help with the disorder. Because an exact cause may be difficult to determine for the client, this would not be appropriate for the nurse to include in the client's plan of care. Explaining the reason for the disorder as being a side effect of prescribed medication could cause the client to discontinue medication necessary to treat other health disorders and should not be done. The nurse should not provide the names of psychologists who treat the disorder.

The nurse is concerned that a client with an alteration in perfusion is at risk for inadequate oxygenation. What should the nurse consider when planning for this client's potential health problem? A) Cluster activities. B) Instruct on deep breathing. C) Medications appropriate to increase heart rate D) Positioning to increase blood return

B) Instruct on deep breathing. The client is at risk for inadequate oxygenation. The nurse should consider teaching the client the importance of deep breathing to increase the amount of oxygen in the body tissues. Clustering activities would negatively impact oxygenation. Periods of rest should occur between activities. The client with oxygenation issues will have tachycardia. The nurse should consider medications that would reduce instead of increase the heart rate. The client should be in the high-Fowler position to improve oxygenation. Positions to increase blood flow to the heart would include Trendelenburg, which would negatively impact oxygenation.

A client is admitted to determine the cause of secondary hypertension. Which diagnostic tests should the nurse suspect the client will be prescribed and need teaching? Select all that apply. A) Cerebral angiogram B) Intravenous pyelogram C) Renal angiogram D) Cardiac catheterization E) Myelogram

B) Intravenous pyelogram C) Renal angiogram When secondary hypertension is suspected, diagnostic tests include an intravenous pyelogram and renal ultrasound to determine if the renal system is the cause of the hypertension. Cerebral angiogram, cardiac catheterization, and myelogram are not diagnostic tests to determine the cause for secondary hypertension.

A client with peripheral vascular disease is experiencing pain. What can the nurse do to assist this client? A) Elevate legs in bed with pillows under the knees. B) Keep the extremities warm with blankets. C) Encourage to ambulate and stand on legs 4 times each day. D) Apply cool compresses to the extremities.

B) Keep the extremities warm with blankets. The nurse should help keep the client's extremities warm with blankets, as heat promotes vasodilation and reduces pain. Cool compresses will constrict vessels and cause more pain. Encouraging the client to ambulate and stand on the legs 4 times each day may be too aggressive. Pillows should not be placed under the knees.

The nurse is planning care for a client with peripheral vascular disease who is at risk for Impaired Skin Integrity. What would be included in this client's plan of care? A) Restrict fluids. B) Keep the skin clean and dry, and moisturize areas of dryness. C) Encourage bed rest with legs elevated on pillows. D) Consult a dietitian for low-protein diet.

B) Keep the skin clean and dry, and moisturize areas of dryness. The client with peripheral vascular disease who is at risk for impaired skin integrity should have meticulous skin care to keep the skin clean, dry, and well-moisturized to prevent skin breakdown. A low-protein diet is not beneficial for wound healing and may not be indicated for this client. A fluid restriction would dry tissues and not promote good skin turgor. Bed rest with legs elevated on pillows could increase the client's pain and would not help with preventing skin breakdown.

A client being treated for a deep venous thrombosis is experiencing pain. What can the nurse do to assist this client? Select all that apply. A) Apply an egg-crate mattress on the bed. B) Maintain bed rest as ordered. C) Apply warm moist heat to the area four times a day. D) Encourage position changes every 2 hours. E) Measure calf and thigh diameter daily.

B) Maintain bed rest as ordered. C) Apply warm moist heat to the area four times a day. E) Measure calf and thigh diameter daily.

The nursing diagnosis Noncompliance related to unknown factors is established for a client with hypertension who admits to occasionally taking prescribed antihypertensive medications. Which behavior should the nurse demonstrate when discussing reasons for noncompliance with this client? A) Indifference B) Nonjudgmental C) Direct D) Confrontational

B) Nonjudgmental The nurse who listens to the client openly and nonjudgmentally will both validate the client's self-esteem and communicate the idea of partnership in the treatment plan for the client. Employing a confrontational attitude is unlikely to elicit a positive response from the client regarding the reason for noncompliance. If the nurse issues a directive by telling the client what to do without listening nonjudgmentally to the problems encountered when taking medications, the client is not likely change his behavior. The nurse who adopts an attitude of indifference is communicating a lack of caring, which will decrease the client's sense of self-esteem.

The nurse is instructing a client on lifestyle changes to prevent the onset of heart disease. What should be included in this teaching? Select all that apply. A) Limit exercise to 15 minutes a day. B) Reduce saturated fats in the diet. C) Avoid cigarette smoking. D) Wear elastic hose. E) Limit fluid intake.

B) Reduce saturated fats in the diet. C) Avoid cigarette smoking. Interventions that would help the client prevent the onset of cardiovascular disease would be to avoid cigarette smoking and reduce saturated fats in the diet. Limiting fluids and wearing elastic hose are not known to prevent the onset of cardiovascular disease. Fifteen minutes of exercise a day may not be enough exercise to prevent the onset of cardiovascular disease.

A male client tells the nurse that he has no idea why his wife wants to stay married to him because he has not been able to "perform" sexually since his prostate surgery. Which diagnosis would be appropriate for this client? A) Ineffective Coping B) Situational Low Self-Esteem C) Hormonal Imbalance D) Sexual Dysfunction

B) Situational Low Self-Esteem The client is viewing himself as less than a man and is concerned with his wife wanting to remain married to him. Situational Low Self-Esteem is the most appropriate nursing diagnosis for the client at this time. Sexual dysfunction is associated with anxiety concerning the cause of the dysfunction, which is not the case for the client. The client may or may not be experiencing ineffective coping. Hormonal imbalance is not a nursing diagnosis.

A nurse working in the Intensive Care Unit (ICU) is caring for a client in a hypertensive emergency due to acute nephritis. The nurse understands that the client's renal system affects blood pressure by: A) Releasing the catecholamines epinephrine and norepinephrine. B) Stimulating the release of renin. C) Stimulating the release of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP). D) Synthesizing and releasing adrenomedullin.

B) Stimulating the release of renin. A drop in renal perfusion stimulates renin release. Renin converts angiotensinogen to angiotensin I, which is then converted to angiotensin II in the lungs. ANP and BNP are released from the atrial cells, not the renal system. The catecholamines epinephrine and norepinephrine are released from the adrenal cortex, not from the kidneys.

The home care nurse assesses an older client's blood pressure as being 150/100 mmHg. When reviewing medications, the client reports taking the blood pressure medication only when feeling tense. What should the nurse instruct this client to do? A) Continue to take medication when feeling tense. B) Take the blood pressure medication as prescribed regardless of feeling tense. C) Take the blood pressure medication at twice the prescribed dosage for 1 day and then resume the daily schedule. D) Contact the physician for an increase in blood pressure medication.

B) Take the blood pressure medication as prescribed regardless of feeling tense. Clients sometimes mistakenly take blood pressure medication only on an as-needed basis. This is incorrect; the client should take the medication as prescribed on a daily basis. The dosage prescribed may be appropriate if taken daily; therefore, it would not need to be increased. To advise the client to increase the medication without a physician consultation would be out of the scope of nursing practice.

Which client is at highest risk for a nonthrombotic pulmonary embolism? A) The pregnant client with gestational diabetes B) The client who postoperative from a femur fracture repair C) The client with a primary lung tumor D) The client who uses intravenous illicit drugs

B) The client who postoperative from a femur fracture repair Fat emboli are the most common nonthrombotic pulmonary emboli. A fat embolism usually occurs after fracture of long bone (typically the femur) releases bone marrow fat into the circulation. The other clients may be at risk for pulmonary embolism; however, they are incorrect choices for the most common cause of nonthrombotic pulmonary emboli.

The nurse is conducting a health history with a client with erectile dysfunction. Which finding(s) could provide a possible cause for the client's problem? Select all that apply. A) Blood pressure of 118/68 mmHg B) Treatment for type 2 diabetes mellitus for 7 years C) Body mass index (BMI) of 24.5 D) Alcohol intake of 4 to 6 beers each day E) Plays golf twice a week

B) Treatment for type 2 diabetes mellitus for 7 years D) Alcohol intake of 4 to 6 beers each day The risk factors for erectile dysfunction are numerous. They include advancing age, diseases such as heart disease and diabetes, trauma, and the use of prescription or illicit drugs. Excessive use of alcohol can also result in erectile dysfunction. Recreational sports, a body mass index within normal limits, and a normal blood pressure would not provide a possible cause for the client's recent experience with the disorder.

The nurse is providing discharge instructions to an older client who is going home after having a total knee replacement. What teaching will the nurse include to prevent the development of a thrombosis or pulmonary embolism? Select all that apply. A) Place pillows under the knees when in bed. B) Use compression stockings. C) Limit ambulation. D) Limit fluids. E) Continue with leg exercises.

B) Use compression stockings. E) Continue with leg exercises. A client being discharged after having orthopedic surgery is at increased risk for pulmonary embolism. The nurse should instruct the client to continue with leg exercises and use compression stockings to reduce the risk of deep vein thrombosis formation. The client should be encouraged to ambulate, avoid placing pillows under the knees, and be well hydrated unless another physiological condition exists that would necessitate a fluid restriction.

The nurse is evaluating teaching provided to a client with peripheral vascular disease. Which client observation indicates teaching has been effective? A) Sitting in a chair with a pillow behind knees B) Washing the lower extremities with mild soap, drying the legs, and applying a light moisturizer C) Sitting in a chair with left leg crossed over the right D) Smoking a pipe instead of cigarettes

B) Washing the lower extremities with mild soap, drying the legs, and applying a light moisturizer The client who is observed washing the legs with mild soap, drying the legs, and applying a moisturizer is putting into practice the instruction regarding peripheral vascular disease. Sitting in a chair with legs crossed or with a pillow behind the knees would indicate further instruction was needed. The client smoking a pipe instead of cigarettes needs additional instruction regarding the hazards of tobacco.

The nurse is planning care for an older client with chronic venous insufficiency. What should the nurse plan to teach this client? A) Keep the legs dependent as much as possible and elevate only when asleep. B) Wear elastic hose as prescribed. C) Standing will prevent the progression of the disease. D) Cross legs only at the knees.

B) Wear elastic hose as prescribed. Care and treatment of a client with peripheral vascular disease includes instruction. The nurse should instruct the client to wear elastic hose as prescribed. The nurse should instruct the client to avoid sitting or standing for long periods of time. The legs should be elevated during rest and when asleep. Crossing the legs should be avoided.

A client admitted with chronic venous insufficiency has an infected wound of the left lower extremity. What will the nurse find when assessing this wound? Select all that apply. A) Pulses absent in the extremity with the wound B) Wound that is pink with skin warm C) Ulceration that is pale in color D) Skin surrounding ulcer that is cool to the touch E) Surrounding skin brown in color

B) Wound that is pink with skin warm E) Surrounding skin brown in color Manifestations of a venous status ulcer would be a pink wound with warm skin and areas of hyperpigmentation. An ulcer that is pale in color with cool skin temperature and absent pulses is manifestations of arterial ulcers.

The nurse is instructing a client about the medication sildenafil (Viagra). Which client statement indicates teaching has been effective? A) "Viagra should be taken with food." B) "I can take Viagra anywhere from 1 to 6 hours before sex." C) "I can take only one pill in a 24-hour period." D) "Grapefruit juice will decrease the effects of Viagra."

C) "I can take only one pill in a 24-hour period." Taking only one pill in a 24-hour period is the recommended dosing for sildenafil (Viagra). Grapefruit juice can lead to increased, not decreased, levels of sildenafil. Sildenafil should be taken on an empty stomach, not with food. The optimum time for administration is 1 hour before sex, but it can be taken up to 4 hours before sex.

The nurse has instructed a client recovering from a pulmonary embolism on long-term anticoagulant therapy. Which client statement indicates that instruction has been effective? A) "I will expect bloody sputum when I brush my teeth." B) "I need to use a soft toothbrush and an electric razor, and avoid injuries." C) "I need to eat a well-balanced diet with green salads." D) "I can expect to be bruised, since this is normal."

C) "I need to eat a well-balanced diet with green salads." Instruction on anticoagulant therapy should include the need to avoid injury, use a soft toothbrush, and use an electric razor. The client should be instructed to obtain a Medic-Alert bracelet that identifies anticoagulant therapy. The client should avoid green salads because of the vitamin K content. The statements about bruising being normal and expecting bloody sputum mean the client is in need of additional instruction on anticoagulant therapy.

The nurse instructor is teaching a group of student nurses regarding the various layers of the heart. Which statements will the nurse include? Select all that apply. A) "The endocardium covers the entire heart and great vessels." B) "The endocardium is the muscular layer of the heart that contracts during each heartbeat." C) "The outermost layer of the heart is the epicardium." D) "The myocardium consists of myofibril cells." E) "The myocardium has four layers."

C) "The outermost layer of the heart is the epicardium." D) "The myocardium consists of myofibril cells." The heart wall consists of three layers of tissue: the epicardium, the myocardium, and the endocardium. The epicardium covers the entire heart and great vessels, and then folds over to form the parietal layer lining the pericardium and adheres to the heart surface. The myocardium, the middle layer of the heart wall, consists of specialized cardiac muscle cells (myofibrils). The endocardium, which is the innermost layer, is a thin membrane composed of three layers. The myocardium is the muscular layer of the heart that contracts during each heartbeat. The outermost layer of the heart is the epicardium.

A client with peripheral vascular disease (PVD) has symptoms of intermittent claudication. The nurse caring for this client understands that intermittent claudication: A) Causes pain that occurs during periods of inactivity. B) Causes pain that increases when the legs are elevated and decreases when the legs are dependent. C) Causes cramping or aching pain in the lower extremities and the buttocks that occurs with a predictable level of activity. D) Is often described as a burning sensation in the lower legs.

C) Causes cramping or aching pain in the lower extremities and the buttocks that occurs with a predictable level of activity. Intermittent claudication is a cramping or aching pain in the calves of the legs, the thighs, and the buttocks that occurs with a predictable level of activity. The pain is often accompanied by weakness and is relieved by rest.

The nurse caring for a client recovering from an abdominal hysterectomy suspects the client is experiencing a pulmonary embolism. What did the nurse assess in this client? A) Nausea B) Decreased urine output C) Dyspnea and shortness of breath D) Activity intolerance

C) Dyspnea and shortness of breath Manifestations of a pulmonary embolism include dyspnea, shortness of breath, pleuritic chest pain, anxiety, apprehension, cough, tachycardia, tachypnea, crackles, and a low-grade fever. Decreased urine output, activity intolerance and nausea are not clinical manifestations of a pulmonary embolism.

The nurse is caring for a client with hypertension. The nurse understands that the client's blood pressure is determined by all the following factors except: A) Pumping action of the heart. B) Peripheral vascular resistance. C) Heart rate. D) Blood volume.

C) Heart rate. The factors which determine blood pressure include the pumping action of the heart; peripheral vascular resistance; and blood volume and viscosity. Heart rate by itself does not determine blood pressure.

The nurse is planning care for a newly admitted client diagnosed with pulmonary embolism. The nurse anticipates the client will need anticoagulant therapy. What is true regarding this therapy for the treatment of this condition? A) It is considered second-line treatment. B) Major hemorrhage is common. C) Heparin and warfarin (Coumadin) are usually initiated at the same time. D) Heparin alters the synthesis of vitamin K-dependent clotting factors, preventing further clots.

C) Heparin and warfarin (Coumadin) are usually initiated at the same time. Heparin and warfarin are usually initiated at the same time for the treatment of pulmonary embolus. Anticoagulant therapy is the standard first-line treatment of pulmonary embolism. While major hemorrhage is uncommon, bleeding may occur. Warfarin, not heparin, alters the synthesis of vitamin K-dependent clotting factors.

A client diagnosed with a pulmonary embolism has a reduction in arterial oxygen saturation level and dyspnea. The nurse would identify which diagnosis as a priority for this client? A) Ineffective Tissue Perfusion B) Anxiety C) Impaired Gas Exchange D) Impaired Physical Mobility

C) Impaired Gas Exchange A reduction in arterial oxygen saturation level and dyspnea indicate the client is experiencing impaired gas exchange. This would be the priority for the client at this time. The client may have ineffective tissue perfusion; however, this is not the priority. The client may be experiencing anxiety; however, this is not the priority at this time either. There is not enough information to determine whether the client is at risk for impaired mobility.

The nurse is planning care for a client with deep venous thrombosis. Which nursing diagnosis would be a priority for this client? A) Risk for Infection related to obstructed venous return B) Excess Fluid Volume related to tissue edema C) Ineffective Tissue Perfusion related to obstructed venous return D) Disturbed Sleep Pattern related to tissue hypoxia

C) Ineffective Tissue Perfusion related to obstructed venous return Ineffective Tissue Perfusion related to obstructed venous return is the correct diagnosis because it identifies the underlying cause. Excess Fluid Volume related to tissue edema and Disturbed Sleep Pattern related to tissue hypoxia are incorrect because they do not identify the underlying cause. Risk for Infection related to obstructed venous return would be a priority if complications of infection were present, however this is not the case.

The nurse is planning care for a client with a pulmonary embolism. Which intervention would assist with the client's decrease in cardiac output? A) Provide oxygen. B) Keep protamine sulfate at the bedside. C) Monitor pulmonary arterial pressures. D) Assess for bleeding.

C) Monitor pulmonary arterial pressures. The client with a pulmonary embolism and decreased cardiac output is at risk for developing right heart failure. The nurse should monitor pulmonary arterial pressures. Assessing for bleeding and keeping protamine sulfate at the bedside would be appropriate for the client with ineffective protection. Oxygen would be appropriate for the client with impaired gas exchange.

A client is admitted with complaints of lower extremity edema and occasional shortness of breath. Which electrocardiogram finding supports that the client is at risk for an alteration in perfusion? A) P wave smooth and round B) Absent U wave C) PR interval 0.30 seconds D) ST segment isoelectric

C) PR interval 0.30 seconds The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds indicate a delay in conduction from the SA node to the ventricles. A P wave should be smooth and round. The ST segment should be isoelectric. The U wave is not normally seen.

A client recovering from a cesarean section is afebrile but is experiencing tenderness, localized heat, and redness of the left leg. What would be the best intervention for the client at this time? A) Encourage to ambulate freely. B) Provide aspirin 650 mg by mouth. C) Place on bed rest. D) Provide Methergine IM.

C) Place on bed rest. These symptoms indicate the presence of superficial thrombophlebitis. The treatment involves bed rest and elevation of the affected limb, analgesics, and the use of elastic support hose. Ambulation would increase the inflammation. Aspirin does have anticoagulant properties but may not be the medication of choice at this time. Methergine is given only for postpartum hemorrhage and would cause vasoconstriction of an already inflamed vessel.

1) What will the nurse most likely assess in a client with right heart failure? A) Leg cramps B) Indigestion C) Reduced circulation to the pulmonary structures D) Reduced urine output

C) Reduced circulation to the pulmonary structures Circulation to the pulmonary structures begins with the right side of the heart. The client with right heart failure will have reduced circulation to these structures. There is no evidence to suggest that right heart failure will cause indigestion or reduced urine output. Not all clients with right heart failure experience leg cramps.

The nurse is completing an assessment on a newly admitted client. What assessment finding would suggest to the nurse that a client is experiencing a deep venous thrombosis? A) Shortness of breath after activity B) Two-plus palpable pedal pulses C) Swelling in one leg with pitting edema D) Bilateral calf tenderness after walking up a flight of stairs

C) Swelling in one leg with pitting edema Manifestations of deep venous thrombosis include swelling in one leg with pitting edema because the clot is obstructing the venous return from the leg. Bilateral calf tenderness may be a normal reaction to the exercise of climbing stairs. Shortness of breath that subsides after activity and two-plus palpable pulses are not manifestations of deep venous thrombosis.

The nurse is preparing to discharge a client recovering from a pulmonary embolism. How should the nurse instruct this client? Select all that apply. A) Limit the use of over-the-counter medications. B) Diet to include green leafy vegetables C) Symptoms of recurrence D) Anticoagulant administration schedule E) Resume normal activity level.

C) Symptoms of recurrence D) Anticoagulant administration schedule The client being discharged after treatment for a pulmonary embolism needs to be instructed in anticoagulant therapy, avoiding green leafy vegetables because of vitamin K, adhering to the physician's prescribed activity level, and avoiding all over-the-counter medications. The nurse should instruct the client in symptoms of bleeding or recurrence of a pulmonary embolism and the schedule for anticoagulation administration.

A client diagnosed with a deep vein thrombosis is receiving intravenous heparin. What does the nurse identify as the priority outcome for this client? A) The client will not disturb the intravenous infusion. B) The client will comply with dietary restrictions. C) The client will not experience bleeding. D) The client will keep the right leg elevated on two pillows.

C) The client will not experience bleeding. An absence of bleeding is a priority outcome for any client receiving anticoagulant therapy. Disturbing the intravenous line could relate to bleeding, but this does not directly correlate with heparin. Dietary restrictions are important but not as high a priority as an absence of bleeding. Elevation of the affected extremity is important but not as high a priority as an absence of bleeding.

A client with peripheral vascular disease asks the nurse what types of exercise would improve the client's condition and overall health. About what should the nurse instruct this client? A) Bicycling B) Weight lifting C) Yoga D) Jogging

C) Yoga Yoga is considered a complementary therapy used to reduce stress and improve circulation. Jogging, weight lifting, and bicycling may or may not help improve the client's diagnosis of peripheral vascular disease.

A client asks for a prescription for tadalafil (Cialis). What would be important for the nurse know prior to planning interventions for this client? A) "Do you have diabetes mellitus?" B) "Do you take blood pressure medication?" C) "Do you have any sexually transmitted infections?" D) "Do you use nitroglycerine?"

D) "Do you use nitroglycerine?" Combining tadalafil (Cialis) with nitroglycerine can lead to serious hypotension. Taking blood pressure medication is not a contraindication to the use of tadalafil (Cialis). Having diabetes mellitus is not a contraindication to the use of tadalafil (Cialis). Having a sexually transmitted infection is not a contraindication to the use of tadalafil (Cialis).

A home care nurse is applying an Unna boot on a client with a stasis ulcer. Which statement will the nurse include when providing client education regarding this therapy? A) "A nurse will change this dressing every 2 days." B) "It is important that you maintain strict bed rest." C) "The dressing will be applied to the entire length of your leg." D) "The dressing I am applying is semi-rigid."

D) "The dressing I am applying is semi-rigid." The Unna boot therapy is a semi-rigid dressing used to treat stasis ulcers. The dressing will be changed every 1-2 weeks, depending on ulcer drainage. The dressing allows a client to be ambulatory and does not make the client maintain strict bed rest. The dressing covers the lower leg and part of the thigh but not the entire leg.

A client with primary hypertension is prescribed terazosin (Hytrin) to treat this condition. The nurse caring for this client understands that the mechanism of action for this medication is: A) Prevents conversion of angiotensin I to angiotensin II. B) Prevents beta-receptor stimulation in the heart. C) Inhibits the flow of calcium ions across the cell membrane of vascular tissue and cardiac cells. D) Blocks alpha-receptors in the vascular smooth muscle.

D) Blocks alpha-receptors in the vascular smooth muscle. Terazosin (Hytrin), an alpha-adrenergic blocker, acts by blocking alpha-receptors in the vascular smooth muscle. ACE inhibitor medications prevent conversion of angiotensin I to angiotensin II. Beta-adrenergic blockers prevent beta-receptor stimulation in the heart. Calcium channel blockers inhibit the flow of calcium ions across the cell membrane of vascular tissue and cardiac cells.

A nurse is treating a client with diabetes mellitus who complains of erectile dysfunction (ED). Which hormonal cause contributes to ED? A) Increased prolactin levels B) Decreased aldosterone levels C) Decreased circulating catecholamines D) Decreased thyroid-stimulating hormone

D) Decreased thyroid-stimulating hormone Hormonal causes of ED include decreased testosterone, decreased prolactin, and alterations in thyroid function. A decrease in thyroid-stimulating hormone (TSH) would be a cause of this disorder. All other choices are incorrect.

A client scheduled for surgery is being instructed in leg exercises and the pneumatic compression device. For the prevention of which postoperative complication are these instructions being provided? A) Infection B) Delayed wound healing C) Contractures D) Deep vein thrombosis

D) Deep vein thrombosis The best care for a pulmonary embolism is prevention. Since surgical clients have an increased risk of developing a pulmonary embolism postoperatively, instructions should include ways to encourage movement, such as leg exercises, and the need for pneumatic compression devices to maintain lower extremity circulation and prevent the development of a deep vein thrombosis. Exercises and pneumatic compression devices do not prevent infection, encourage wound healing, or prevent contractures.

The nurse identifies the diagnosis Ineffective Peripheral Tissue Perfusion related to decreased arterial flow to extremities as appropriate for a client. What should the nurse instruct the client to do to improve blood flow? A) Cross the legs at the knees when seated. B) Use a heating pad to increase warmth. C) Elevate the feet while reclining. D) Position with the extremities dependent.

D) Position with the extremities dependent. Positioning with the extremities dependent is correct because gravity promotes arterial flow to the dependent extremity, increasing tissue perfusion. Crossing the legs at the knees when seated is not recommended because this position compresses partially obstructed arteries and impairs blood flow. Elevating the feet while reclining is not recommended because elevating the feet works against gravity and will further impede blood flow. Using a heating pad to increase warmth is not recommended because external heating devices could increase the risk of burns in a client with impaired circulation and decreased sensation.

A nurse caring for a client with a pulmonary embolism expects to find which diagnostic result? A) Patchy infiltrates on chest x-ray B) Metabolic alkalosis on arterial blood gas C) Elevated CO2 level found on end-tidal carbon dioxide monitor D) Tachycardia and nonspecific T-wave changes on EKG

D) Tachycardia and nonspecific T-wave changes on EKG With pulmonary embolism, tachycardia and nonspecific T-wave changes occur on EKG. The client with a pulmonary embolism will likely have respiratory alkalosis from rapid breathing, not metabolic alkalosis. The end-tidal carbon dioxide monitor (EtCO2) will be decreased, not increased, due to rapid breathing.

The nurse is planning care for a group of clients. Which client should the nurse realize has the greatest risk for developing deep venous thrombosis? A) The client recovering from laparoscopic gallbladder surgery B) The client admitted with new-onset type II diabetes mellitus C) The client admitted with community-acquired pneumonia D) The client recovering from knee replacement surgery

D) The client recovering from knee replacement surgery Up to 60% of clients recovering from total knee replacement surgery can develop a deep venous thrombosis. This is because of the procedure and prolonged immobility after surgery. The client admitted with new-onset type II diabetes mellitus, the client admitted with community-acquired pneumonia, and the client recovering from laparoscopic gallbladder surgery would be at a lower risk for deep venous thrombosis because prolonged immobility will not occur.