Perfusion Adaptive Quizzing

Which clinical finding can the nurse expect to identify when assessing a client with varicose veins? SELECT ALL THAT APPLY a) discolored toenails b) reports of leg fatigue c) localized heat in a calf d) reddened areas on a calf e) tortuous veins in the legs f) pain in lower extremities when standing

b) reports of leg fatigue e) tortuous veins in the legs f) pain in lower extremities when standing

Which action would the nurse PRIORITIZE after applying pressure to the nose of a client who is being treated for uncontrolled hypertension and develops a nosebleed? a) add humidity to the client's oxygen b) teach the client how to avoid nosebleeds c) assess the client's blood pressure d) obtain the client's pulse rate

c) assess the client's blood pressure

Which prescribed action would the nurse take FIRST when a client who is admitted to the emergency department with a blood pressure of 240/150 mmHg reports severe headache, blurred vision, and swelling of the ankles? a) obtain a glucose blood sample b) collect urine and blood samples c) assess the client's pulse and respirations d) determine the amount of ankle edema

c) assess the client's pulse and respirations

Which laboratory result will be important for the nurse to review when a client is admitted to the hospital with a long history of uncontrolled hypertension? a) blood glucose level b) white blood cell count c) blood urea nitrogen d) lactic dehydrogenase

c) blood urea nitrogen Rationale: hypertension leads to changes in renal blood flow and eventually to decreased renal function, which is tested with blood urea nitrogen levels

Which action would the home health nurse take when caring for a client with a pink and moist left leg venous stasis ulcer? a) teach the client to keep the left leg in a dependent position to improve blood flow b) monitor for increases in bruising or bleeding caused by use of anticoagulant medications c) clean the wound with normal saline and apply prescribed hydrocolloid dressings weekly d) educate the client about the need for vascular surgery to improve blood flow to the wound

c) clean the wound with normal saline and apply prescribed hydrocolloid dressings weekly

Which finding in a client with right calf venous thrombosis is MOST important to communicate to the health care provider? a) severe right calf pain b) right calf redness and swelling c) oxygen saturation 89% d) HR of 136 beats/min

c) oxygen saturation 89% Rationale: may indicate pulmonary embolism

Which finding will be MOST important to communicate to the health care provider when the clinic nurse is assessing a client with thromboangiitis obliterans (Buerger disease)? a) age 41 years b) burning leg pain c) taking daily nifedipine d) continue tobacco use

d) continue tobacco use

Which information will the nurse include when teaching a client with venous insufficiency about prevention of venous thrombosis? a) wear snug-fitting pants b) sit with the knees flexed c) apply warm soaks to the legs daily d) put on compression stockings before arising

d) put on compression stockings before arising

After the nurse has finished teaching a postoperative client about prevention of pulmonary embolism, which client statement indicates that the teaching has been effective? a) "I will avoid crossing my legs" b) "Pillows placed under my knees will help avoid clots" c) "Staying on bed rest as long as possible is best for me" d) "Three times every day I will massage my lower legs to get blood moving"

a) "I will avoid crossing my legs"

Which finding in a client who has had major abdominal surgery indicates a possible venous thrombosis of the leg? SELECT ALL THAT APPLY a) edema of the ankle b) skin breakdown over the shin c) pruritus on the side of the calf d) tender area in the posterior lower leg e) warmth along the course of the involved vessel

a) edema of the ankle d) tender area in the posterior lower leg e) warmth along the course of the involved vessel

Which client action indicates that the teaching has been effective after the nurse provides discharge teaching for a client who had a femoropopliteal bypass graft? a) walking for 10 minutes twice a day b) elevating the legs when sitting and lying c) taking a hot bath before going to bed d) discontinuing prescribed daily aspirin

a) walking for 10 minutes twice a day

Which clinical finding would the nurse expect for a client with hypertensive emergency? a) increased urine output b) severe pounding HA c) HR 110 beats/min d) weak and thready radial pulses

b) severe pounding HA

Which mechanism would the nurse attempt to increase to prevent postoperative deep vein thrombosis? a) coagulability of the blood b) velocity of the venous return c) effectiveness of internal respiration d) oxygen-carrying capacity of the blood

b) velocity of the venous return Rationale: venous stasis is the major predisposing factor of pulmonary emboli, venous flow velocity should be increased through activity

Which assessment finding indicates a need for the nurse to consult with the health care provider before administering the prescribed metoprolol to a client with stable angina? a) blood pressure 142/90 mmHg b) report of chest pain when walking c) sinus bradycardia, rate 54 on monitor d) large Q waves on the electrocardiogram

c) sinus bradycardia, rate 54 on monitor

Which information will the nurse include when providing instructions to a client with the diagnosis of primary hypertension who is started on a regimen of hydrochlorothiazide? a) a common side effect is decreased sexual libido b) one dose should be omitted if dizziness occurs when standing up c) the client should adjust the dosage daily based on the client's blood pressure d) an antihypertensive medication will likely be required for the remainder of life

d) an antihypertensive medication will likely be required for the remainder of life

Which action will the nurse take when caring for a client with chronic arterial insufficiency of the legs who refuses the prescribed dose of aspirin (ASA) and states "my legs are not painful"? a) explain the reason for the medication and encourage the client to take it b) withhold the medication at this time and return to check with the client again in 30 minutes c) withhold the medication and tell the client to ask for it if the legs uncomfortable d) request that the client take the medication and explain that it prevents the client from being uncomfortable in the next few hours

a) explain the reason for the medication and encourage the client to take it

Which adverse effect would a nurse monitor for when caring for a client with hypertension who is prescribed metoprolol? a) hirsutism b) bradycardia c) restlessness d) angina

b) bradycardia

Which finding in a client seen at the outpatient clinic supports a diagnosis of an arterial ulcer? SELECT ALL THAT APPLY a) lack of hair b) thickened toenails c) copious ulcer drainage d) diminished pedal pulse e) brown skin discoloration

a) lack of hair b) thickened toenails d) diminished pedal pulse

Which clinical finding would the nurse expect to identify when caring for a client with a left leg venous thrombosis? SELECT ALL THAT APPLY a) pain in the left calf b) intermittent claudication c) redness in the affected area d) swelling of the lower left leg e) ecchymotic areas at the left ankle f) localized warmth in the lower left leg

a) pain in the left calf c) redness in the affected area d) swelling of the lower left leg f) localized warmth in the lower left leg

Which finding would the nurse expect when assessing a client with peripheral arterial disease? SELECT ALL THAT APPLY a) pallor of feet b) warm extremities c) ulcers on the toes d) thick, hardened skin e) delayed capillary refill

a) pallor of feet c) ulcers on the toes e) delayed capillary refill

The health care provider has prescribed enoxaparin 1mg/kg for a client who had a total knee replacement. The client weighs 187 lb. This medication is available in a concentration of 30mg/0.3mL. Which dose will the nurse administer in milliliters? a) 0.8mL b) 0.85mL c) 0.9mL d) 0.95mL

b) 0.85mL

Which adverse effect would a nurse monitor for in a client taking clopidogrel? a) nausea b) epistaxis c) chest pain d) elevated temperature

b) epistaxis Rationale: anti-platelet epistaxis = nose bleed

Which findings occur with orthostatic hypotension? SELECT ALL THAT APPLY a) reflex tachycardia b) feeling of faintness c) increased cardiac output d) increased diastolic pressure e) decreased systolic pressure

b) feeling of faintness e) decreased systolic pressure

Which client between the ages of 25 and 55 years would the nurse assess first? a) male client with a hemoglobin of 15.9 b) female client on warfarin with an INR of 7.5 c) female client taking daily calcium supplements with a serum calcium level of 9.4 d) male client with a blood urea nitrogen (BUN) of 20 and a creatinine of 1

b) female client on warfarin with an INR of 7.5 Rationale: This is an elevated result, normal range is between 2-3

Which topic would the nurse include when doing discharge teaching about ways to avoid another venous thrombosis when caring for a client hospitalized with deep vein thrombosis? a) daily aspirin use b) frequent ambulation c) warm soaks to legs d) avoidance of cold

b) frequent ambulation

Which adverse effect of valsartan, an angiotensin II receptor antagonist, will a nurse monitor for when prescribed for a client? a) constipation b) hyperkalemia c) hypertension d) change in visual acuity

b) hyperkalemia

Which nursing intervention will be implemented when the health care provider prescribes verapamil to be administered intravenously to a 70-year-old client with hypertension? a) monitor the electrocardiogram for reflex tachycardia b) keep the client in bed for an hour after giving the medication c) dilute the dose in 50mL of normal saline and administer it over 15 minutes d) assess the client for wheezes and history of asthma before administering the medication

b) keep the client in bed for an hour after giving the medication

Which information obtained by the nurse about a client would represent a risk factor for the client's admission diagnosis of hypertension? SELECT ALL THAT APPLY a) daily use of 1 aspirin b) occasional cocaine use c) reduced hemoglobin level d) African American/Black heritage e) increased high-density lipoprotein (HDL)

b) occasional cocaine use d) African American/Black heritage Rationale: Cocaine caused tachycardia and hypertension

Which information will the nurse include when teaching a client who has a new diagnosis of Raynaud disease? SELECT ALL THAT APPLY a) medications will be needed to control the symptoms b) stop cigarette smoking and other tobacco use c) wear gloves when getting food from the freezer d) plan to take daily low-dose aspirin tablet e) avoid going quickly from a warm to a cold environment

b) stop cigarette smoking and other tobacco use c) wear gloves when getting food from the freezer e) avoid going quickly from a warm to a cold environment

Which antihypertensive medication class would the nurse identify as the likely cause of the cough in a client taking multiple medications for hypertension who develops a persistent, hacking cough? a) thiazide diuretics b) calcium channel blockers c) direct renin inhibitors d) ACE inhibitors

d) ACE inhibitors

Which action would the nurse take when the thigh-high antiembolism stockings that have been prescribed for a client with varicose veins fit on the lower legs but are too small to fit over the thighs? a) slightly slit the top of the stockings to relieve pressure b) leave the antiembolism stockings off to prevent tissue damage c) roll the top of the stockings to below the knees to limit popliteal pressure d) ask the health care provider if an elastic bandage can be used in place of the stockings

d) ask the health care provider if an elastic bandage can be used in place of the stockings

Which action would the nurse take after obtaining client blood pressures of 172/104 mmHg and 164/98 mmHg during a blood pressure screening? a) provide health teaching about. a low-sodium diet b) call the paramedics for transport to the hospital c) suggest ways to decrease the client's stress level d) refer the client to a primary health care provider

d) refer the client to a primary health care provider Rationale: needs further evaluation by a HCP