EAQ 2

A client presents with bilateral leg pain and cramping in the lower extremities. The client has a history of cardiovascular disease, diabetes and varicose veins. To guide the assessment of the pain and cramping, the nurse would include which question when completing the initial assessment?

"Does walking for long periods of time increase your pain?"

Which statement indicates that further teaching is needed after the nurse completes teaching for a client with foot pain who has peripheral arterial disease?

"I will elevate my foot."

Which response will the nurse make to explain the discoloration when a client with venous insufficiency has questions about the brownish discoloration of the skin on the legs?

"There is a leakage of red blood cells [RBCs] through the vein wall."

Which instruction will the home health nurse include when teaching a client with peripheral artery disease?

-"Avoid crossing your legs." -"Inspect your feet daily." -"Do not use compression stockings."

Which adverse hemodynamic effect typically occurs when a client develops tachycardia?

-decreased ventricular filling time -lower cardiac output -weaker pulse quality

Which finding would the nurse expect when assessing a client with peripheral arterial disease?

-pallor of feet -ulcers on the toes -delayed capillary refill

Which information will the nurse include when teaching a client who has a new diagnosis of Raynaud disease?

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

Which criteria indicates that a client on a cardiac monitor is in sinus rhythm?

-the RR intervals are relatively consistent -one P wave precedes each QRS complex

A client who is scheduled for endovennous ablation of the saphenous vein asks the nurse, "How did I get varicose veins?" Which factors in the client's history will the nurse discuss?

-works as cashier in a grocery store -reports family history of venous insufficiency

Which action will the nurse taken when the international normalized ratio (INR) for a client receiving warfarin for venous thrombosis is 4.6?

notify the health care provider of the laboratory results

Which action would the nurse anticipate taking when a client develops third degree atrioventricular block with a heart rate of 30 beats/minute?

obtain the transcutaneous pacemaker

Which finding in a client with right calf venous thrombosis is most important to communicate to the health care provider?

oxygen saturation 89%

Which dysrhythmia would the nurse identify on the client's electrocardiogram strip?

premature ventricular complexes

When taking the health history for a client admitted with heart failure, which assessment finding will the nurse expect the client to report?

using several pillows at night to sleep

Which diagnostic test would a nurse anticipate teaching about when a client who has had abdominal surgery reports pain and swelling in the right leg?

venous ultrasound of pelvis and legs

Which action would help prevent venous thrombosis in a client during the perioperative period?

-administer subcutaneous heparin injections -assist the client to don antiembolism stockings -apply pneumatic compression devices to the legs

Which assessment finding is consistent with a client diagnosis of right-sided heart failure?

-distended abdomen -dependent edema -decreased appetite

Which assessment finding would the nurse expect when a client is diagnosed with left-sided congestive heart failure?

-dyspnea -crackles -frequent cough

Which manifestation in a client with heart failure indicates digoxin toxicity?

-nausea -yellow vision -irregular pulse

Which part of the electrocardiogram (ECG) represents depolarization of the ventricles?

QRS interval

Which medication is used to treat a client whose cardiac monitor reveals several runs of ventricular tachycardia?

amiodarone

Which action would the nurse taken 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?

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

Which medication prescribed for a client with an acute episode of heart failure would the nurse question?

beta blocker

Which explanation would the nurse include when teaching a client with heart failure about the reason for a low-sodium diet?

decreased fluid retention

Which action would the nurse take to prevent venous thrombus formation after abdominal surgery?

encourage the client to ambulate multiple times daily

Which action would a nurse perform first for a client with a dysrhythmia?

ensure airway-breathing-circulation (ABC)

Which term will the nurse use to document when a client with peripheral arterial disease tells the nurse about having leg pain and weakness after walking a short distance?

intermittent claudication

Which rhythm would the nurse document when observing the following dysrhythmia on a client's cardiac monitor?

ventricular fibrillation

Which dysrhythmia is this client on the telemetry unit exhibiting?

ventricular tachycardia

Which action would the nurse include in the post procedure plan of care for a client with peripheral arterial disease who is scheduled for a femoral angiogram?

check pedal pulses every 15 minutes post procedure

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)?

continued tobacco use

Which possible complication would a nurse monitor for when a client develops of venous thrombosis in the left calf?

pulmonary embolism

Which assessment finding by the nurse caring for a client with new-onset atrial fibrillation would be the most important to communicate to the health care provider?

sudden vision change

The nurse is caring for a client on bed rest. Which nursing intervention would prevent a pulmonary embolism?

teach the client how to exercise the legs

Which information will the nurse include when explaining to a client with atrial tachycardia how the use of the Valsalva maneuver may decrease the client's heart rate?

the vagus nerve is stimulated