Vascular Disorder NCLEX questions

Which of the following client's is at greatest risk for Buerger's disease? 1. A 29 year old male with a 14 year history of cigarette smoking 2. A 38 year old female who is taking birth control pills 3. A 54 year female with adult onset diabetes. A 65 year old make with atherosclerosis

1. A 29 year old male with a 14 year history of cigarette smoking

The nurse is obtaining a blood sample for a partial thromboplastin time test prescribed for a client who is taking heparin. It is 0500 when drawing the blood. What should the nurse do? Select all that apply 1. Awake the client 2. Check the armband for client identification number and compare with the prescription 3. Label the sample vial in front of the client 4. Verify the room number with the room assignment 5. Ask the client to state his/her name

1. Awake the client 2. Check the armband for client identification number and compare with the prescription 3. Label the sample vial in front of the client 5. Ask the client to state his/her name

A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first? 1. Elevate the head of bed 30 to 45 degrees. 2. Encourage the client to cough and deep breathe. 3. Auscultate the lungs to detect abnormal breath sounds. 4. Contact the HCP.

1. Elevate the head of the bed 30 to 45 degrees.

A well nourished client is admitted with a stasis ulcer. The nurse assesses the ulcer and finds excavation of the skin surface as a result of sloughing of inflammatory necrotic tissue. The HCP has prescribed the ulcer to be flushed with a fibrinolytic agent. Which goals are appropriate for this client? Select all that apply 1. Increase oxygen to the tissues 2. Prevent direct trauma to the ulcer 3. Improve nutrition 4. Prevent infection 5. Reduce pain

1. Increase oxygen to the tissues 2. Prevent direct trauma to the ulcer 4. Prevent infection 5. Reduce pain

A clinically obese client with moderately painful varicose veins chooses self-care options for managing the variscosities. The nurse should coach the client to follow which healthcare practicies? Select all that apply 1. Lose weight 2. Wear compression stockings 3. Apply lotion to the veins 4. Elevate the legs 4. Sleep with pillows under the knees

1. Lose weight 2. Wear compression stockings 4. Elevate the legs

The nurse is making the client assignment for a group of clients. The personnel include the RN, a LVN, and a CNA. Which client would the nurse assign to the LVN? 1. a client who is undergoing femoropopliteal bypass graft surgery this morning and needs the preoperative check list completed. 2. a stable client with thrombophlebitis of the LLE with limited mobility and requiring a complete bed bath 3. a client with a palpable abdominal mass, painful lower extremities, and a decreasing BP 4. a client with intermittent claudication who needs frequent assistance with getting out of bed and ambulating

1. a client who is undergoing femoropopliteal bypass graft surgery this morning and needs the preoperative check list completed.

The client is admitted with left lower leg pain, a positive Homan's sign, and a temperature of 100.4 F. The nurse should assess the client further for signs of: 1. aortic aneurysms 2. DVT in the left leg 3. IV drug abuse 4. intermittent claudication

2. DVT in the left leg

The client with DVT has been receiving warfarin for 2 mos. The client is to go to an anticoagulant monitoring lab every 3 weeks. The last visit to the lab was 2 weeks ago. The client reports bleeding gums, increased bruising, and dark stools. What should the nurse instruct the client to do? 1. Decrease the dose of the warfarin 2. Return to the lab for analysis of Prothrombin times 3. Decrease the amount of vitamin K in the diet 4. Notify the HCP about the bleeding

2. Return to the lab for analysis of Prothrombin times

A client weighs 300 lb and has a history of DVT and thrombophlebitis. When coaching a client about behaviors to maintain health, the nurse determines that the client has understood the nurse's instructions when the client states a willingness for: 1. limit exercise that involves walking 2. lose weight by following a reduced-calorie balanced diet 3. perform leg lifts every 4 hrs to strengthen hamstring muscles 4. wear knee-high stockings, rolled at the top to hold the stockings up

2. lose weight by following a reduced-calorie balanced diet

A client who is being discharged after a hospitalization for thrombophlebitis will be riding home in a car. During the 2 hour ride, what should the nurse advise the client to do? 1. perform arm circles while riding in the car 2. perform ankle pumps and foot range of motion exercises 3. elevate the legs while riding in the car 4. take an ambulance home

2. perform ankle pumps and foot range of motion exercises

A client has returned to the surgical care unit after having femoral-popliteal bypass grafting. Indicate in which order from first to last the nurse should conduct assessment of this client. All options must be used. 1. postoperative pain 2. peripheral pulses 3. urine output 4. incision site

2. peripheral pulses 4. incision site 3. urine output 1. postoperative pain

The primary goal for the client with Buerger's disease is to prevent 1. Embolus formation 2. Fat embolus formation 3. Thrombus formation 4. Thrombophlebitis

3. Thrombus formation

A client has an emergency embolectomy for an embolus in the femoral artery. After the client returns from the recovery room, in what order, from first to last, should the nurse provide care? All options must be used. 1. Administer pain medications 2. Draw blood for lab studies 3. Regulate the IV infusion 4. Monitor the pulses 5. Inspect the dressing

4. Monitor pulses 5. Inspect the dressing 3. Regulate the IV infusion 1. Administer pain meds 2. Draw blood for lab studies

When assessing an individual with peripheral artery disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg? 1. aching pain in the left calf. 2. burning pain in the left calf. 3. numbness and tingling in the left leg. 4. coldness of the left foot and ankle.

4. coldness of the left foot and ankle.

A client is on complete bed rest. The nurse should initiate measures to prevent which complication of bed rest? 1. air embolus 2. fat embolus 3. stress fractures 4. thrombophlebitis

4. thrombophlebitis

The nurse interviews a 22 year old female client who is scheduled for abdominal surgery the following week. The client is obese and uses estrogen based oral contraceptives. The client is at high risk for development of: 1. atherosclerlosis 2. diabetes 3. Raynaud's disease 4. thrombophlebitis

4. thrombophlebitis

In order to prevent DVT following abdominal surgery, the nurse should 1. limit fluids to 1,000 mL in 24 hrs 2. encouraging deep breathing 3. assist the client to remain sedentary 4. use pneumatic compression stockings

4. use pneumatic compression stockings

The nurse is instructing a client who is at risk for peripheral artery disease how to use knee-length elastic stocking (support hose). What instructions should the teaching plan include? Select all that apply. 1. Apply the elastic stockings before getting out of bed. 2. Remove the stocking if swelling occurs. 3. Remove the stocking every 8 hrs, elevate the feet, and reapply in 15 mins. 4. Once the stocking have been pulled over the calf, roll the remaining stocking down to make a cuff. 5. Keep the stockings in place for 48 hrs, and reapply using a clean pair of stockings.

Ans: 1. Apply the elastic stocking before getting out of bed. 3. Remove the stocking every 8 hrs, elevate the feet, and reapply in 15 mins.

A client with a recent diagnosis of DVT has sudden onset of SOB and CP that increases with deep breath. The nurse should first: 1. assess the oxygen saturation 2. call the HCP 3. administer morphine sulfate, 2 mg IV 4. perform ROM exercises in the involved leg

Ans: 1. Assess the oxygen saturation

A client with DVT suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first? 1. Elevate the HOB 30 to 45 degrees. 2. Encourage the client to cough and deep breath 3. Auscultate lungs to detect abnormal breath sounds 4. Contact the HCP

Ans: 1. Elevate the HOB 30 to 45 degrees

A client is receiving pentoxifylline for intermittent claudication. The nurse should determine the effectiveness of the drug by asking if the client: 1. has less pain in the legs 2. can wiggle the toes 3. is urinating more frequently 4. is less dizzy

Ans: 1. has less pain in the legs

The nurse is caring for a client who has just had an ankle-brachial index (ABI) test. The left arm blood pressure was 160/80 mm Hg, and a palpable systolic blood pressure of the left lower extremity was 130/60 mm Hg. These findings suggest that the client has: 1. mild peripheral artery disease. 2. moderate peripheral artery disease. 3. no apparent occlusion in the left lower extremity. 4. severe peripheral artery disease.

Ans: 1. mild peripheral artery disease

The client with peripheral artery disease has been prescribed diltiazem. The nurse should determine the effectiveness of this medication by assessing the client for anxiety. 1. relief of anxiety 2. sedation 3. vasoconstriciton 4. vasodilation

Ans: 1. vasodilation

A client is talking with the nurse about unslightly varicose veins and their discomfort. What information should the nurse provide to the client? 1. Avoid walking to reduce the discomfort 2. Keep the legs elevated when sitting or lying down 3. Sclerotherapy can be used for cosmetic improvement 4. Contact a surgeon to perform a femoral-popliteal bypass graft

2. Keep the legs elevated when sitting or lying down

The client with peripheral artery disease reports both legs hurt when walking. What should the nurse instruct the client to do? 1. Avoid walking when the pain occurs. 2. Rest frequently with the legs elevated. 3. Wear support stockings. 4. Enroll in a supervised exercise training program.

4. Enroll in a supervised exercise training program.

The nurse assesses a client with a 5 x 2 stasis ulcer just above the left malleolus. The wound is open with irregular, reddened, swollen edges, and there is a moderate amount of yellowish tan drainage coming from the wound. The client verbalizes pressure-type pain and rates the discomfort at 7 on a scale of 0 to 10. To maintain tissue integrity, the primary nursing goal should focus on 1. administering prescribed analgesics 2. applying lanolin lotions to the left ankle stasis ulcer 3. encouraging the client to sit up in a chair four times per day 4. keeping pressure of bed linens off the area

4. keeping pressure of bed linens off the area

The nurse is planning care for a client on complete bed rest. The plan of care should include all except: 1. turning every 2 hrs 2. passive an active ROM exercises 3. use of TED support hoses 4. maintaining the client in the supine position

4. maintaining the client in the supine position

A client is admitted with a diagnosis of thrombophlebitis and DVT of the right leg. A loading dose of heparin has been given in the emergency department, and IV heparin will be continued for the next several days. The nurse should develop a plan of care for this client that will involve: 1. administering aspirin as prescribed 2. encouraging green leafy vegetables in the diet 3. monitoring the clients PT. 4. monitoring the clients aPTT and INR.

4. monitoring the clients aPTT and INR

A client underwent surgery to repair an abdominal aortic aneurysm. The surgeon made an incision that extends from the xiphoid process to the pubis. At 1200 hours 2 days after surgery, the client has abdominal distention. What is most likely contributing to the client's abdominal distention? 1. NG tube 2. Ice chips 3. IV fluid intake 4. morphine

4. morphine

A client with Buerger's disease has established a goal to stop smoking. Which medication would be the most helpful in attaining this goal? 1. Zyban (Bupropion) 2. Nicotine (Nicotrol) 3. Nitroglycerin (Tridil) 4. Ibuprofen (Advil)

1. Zyban (Bupropion)

A client is on complete bed rest. The nurse should initiate measures to prevent which complication of bed rest? 1. air embolus 2. fat embolus 3. stress fractures 4. thrombophlebitis

Ans: 4. thrombophlebitis

The client with Raynaud's phenomenon has coldness and numbness in the fingers. Which is an early sign of vasoconstriction? 1. cyanosis 2. gangrene 3. pallor 4. rubor

Ans: 3. pallor

A client has sudden, severe pain in the back and chest, accompanied by shortness of breath. The client describes the pain as a "tearing" sensation. The HCP suspects the client is experiencing a dissecting aortic aneurysm. The emergency supply cart is brought into the room because one complication of a dissecting aneurysm is 1. cardiac tamponade 2. stroke 3. pulmonary edema 4. myocardial infarction

1. cardiac tamponade

The nurse is planning care for a client who has just returned to the medical-surgical unit following repair of an aortic aneurysm. The nurse first should assess the client for 1. decreased urinary output 2. electrolyte imbalance 3. anxiety 4. wound infection

1. decreased urinary output

The nurse should instruct a client who has been diagnosed with Raynaud's phenomenon to 1. immerse the hands in cold water during an episode 2. wear light garments when the temperature gets below 50 F 3. wear gloves when handling ice or frozen foods 4. live in a cold climate

Ans: 3. wear gloves when handling ice or frozen foods

A client is scheduled to undergo right axillary-to-axillary artery bypass surgery. Immediately following surgery, to prevent infection, the nurse should: 1. assess the temperature in the right arm. 2. monitor the radial pulse in the right arm. 3. protect the extremity from cold. 4. avoid using the arm for venipuncture.

Ans: 4. avoid using the arm for venipuncture

A client with peripheral artery disease coronary artery disease, an chronic obstructive pulmonary disease takes theophylline 200 mg twice daily every day and digoxin 0.5 mg once a day. The healthcare provider (HCP) now prescribes pentoxifylline. To prevent adverse effects, the nurse should monitor the client's 1. digoxin level 2. PTT 3. serum cholesterol level 4. theophylline level

Ans: 4. theophylline level

A client had a repair of a thoracoabdominal aneurysm 2 days ago. Which findings should the nurse consider unexpected and report to the HCP immediately? 1. abdominal pain at 5 on a scale of 0 to 10 for the last 2 days 2. heart rate of 100 after ambulating 200 feet 3. urine output of 2,000 mL in 24 hrs 4. weakness and numbness in the lower extremities

4. weakness and numbness in the lower extremities

A client with venous thrombus reports having pain in the legs. What should the nurse do first? 1. Elevate the foot of the bed 2. Elevate the legs of using a pillow under the knees 3. Encourage adequate fluid intake 4. Massage the lower legs

1. Elevate the foot of the bed

The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client's pain, and the client refuses to get out of bed to ambulate as prescribed. The nurse contacts the HCP, explains the situation, and provides information about drug dose, frequency of administration, the client's vital signs, and the client's score on the pain scale. The nurse requests a prescription for a different, or stronger, pain medication. The HCP tells the nurse that the current prescription for pain medication is sufficient for this client and that the client will feel better in several days. The nurse should next 1. explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed. 2. ask the surgical resident to write a prescription for a stronger pain medication 3. wait until the next shift and ask the nurse on that shift to contact the HCP 4. report the incident to the team leader

1. explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed.

The nurse is caring for a client with venous thrombosis of the left lower extremity. To prevent further tissue damage, it is important for the nurse to observe for which finding? 1. blood pressure and heart rate changes 2. gradual or acute loss of sensory and motor function 3. metabolic acidosis 4. swelling in the left lower extremity

2. gradual or acute loss of sensory and motor function

A client is scheduled to have an arteriogram. During the arteriogram, the client reports having nausea, tingling, and dyspnea. The nurse's immediate action should be to: 1. administer epinephrine 2. inform the healthcare provider (HCP). 3. administer oxygen 4. inform the client that the procedure is almost over

Ans: 2. inform the healthcare provider (HCP)

The nurse is developing a discharge teaching plan for a client who had a graft insertion for an abdominal aortic aneurysm 4 days ago. The nurse reviews the clients chart for information about the client's history. Key findings are noted in the chart below. Patient smokes four cigars a month, BP ranges from 150/76 to 170/98 mm Hg, HR 90-100 bpm, respiration 12-18 bpm, temp 99.9 F. Based on the data and expected outcomes, which should the nurse emphasize in the teaching plan? 1. food intake 2. fluid volume 3. skin integrity 4. tissue perfusion

4. tissue perfusion

A client with Raynaud's phenomenon is considering having a sympathectomy. This nurse should tell the client that the surgery is performed: 1. in the early stages of the disease to prevent further circulatory disturbances 2. when the disease is controlled by medication 3. when the client is unable to control stress-controlled vasospasm 4. when all other treatment alternatives have failed

4. when all other treatment alternatives have failed

A client who is being discharged after hospitalization for thrombophlebitis will be riding home in a car. During the 2 hr ride, what should the nurse advise the client to do? 1. perform arm circles while riding in the car 2. perform ankle pumps and foot ROM exercises 3. elevate the legs while riding in the car 4. take an ambulance home

Ans: 2. perform ankle pumps and foot ROM exercises

During an initial assessment of a client diagnosed with Raynaud's phenomenon, the nurse notes a sudden color change from pink to white in the fingers. The nurse should first assess 1. appearance of cyanosis 2. radial pulse 3. SpO2 of the affected fingers 4. blood pressure

Ans: 2. radial pulse

A client has peripheral artery disease of both lower extremities. The client tells the nurse, "I have really tried to manage my condition well." Which example indicates the client is using appropriate care management strategies? 1. The client rests with the legs elevated above the level of the heart. 2. The client walks slowly but steadily for 30 mins twice a day. 3. The client limits activity to walking around the house. 4. The client wears antiembolism stockings at all times when out of bed.

Ans: 2. The client walks slowly but steadily for 30 mins twice a day.

A client is receiving cilostazol for peripheral artery disease causing intermittent claudication. The nurse determines this medication is effective when the client reports: 1. "I am having fewer aches and pains." 2. "I do not have headaches anymore." 3. "I am able to walk further without leg pain." 4. "My toes are turning grayish black in color."

Ans: 3. "I am able to walk further without leg pain."

A client with a history of coronary artery disease (CAD) has been diagnosed with peripheral artery disease. The healthcare provider (HCP) started the client on pentoxifylline once daily. Approximately 1 hr after receiving the initial dose of pentoxifylline, the client reports having chest pain. The nurse should first: 1. initiate the rapid response team 2. contact the HCP 3. have the client rest in bed 4. start an intravenous infusion of normal saline

Ans: 2. contact the HCP

A client with peripheral artery disease is recovering from surgery to insert an aortofemoral-popliteal bypass graft. When developing a postoperative education plan, which question by the nurse will provide the most helpful information? 1. "How did you manage your health before admission?" 2. "How could you walk without pain before surgery?" 3. "What is your home environment like?" 4. "Do you have problems with urine retention?"

Ans: 1. "How did you manage your health before admission?"

An obese client taking warfarin has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply. 1. Apply lanolin or petroleum jelly to intact skin. 2. Follow a reduced-calorie, reduced-fat diet. 3. Inspect the involved areas daily for new ulcerations. 4. Limit activities of daily living (ADLs). 5. Use an electric razor to shave.

Ans: 1. Apply lanolin or petroleum jelly to intact skin. 2. Follow a reduced-calorie, reduced-fat diet. 3. Inspect the involved areas daily for new ulcerations. 5. Use an electric razor to shave.

A client with peripheral artery disease has chronic, severe bilateral pretibial and ankle edema; the client is on complete bed rest. To maintain skin integrity, what should the nurse do? 1. Administer pain medication 2. Ensure fluid intake of 3,000 mL per 24 hrs. 3. Turn the client every 1 to 2 hrs. 4. Maintain hygiene.

Ans: 3. Turn the client every 1 to 2 hrs.

The nurse is assessing a client who has a history of peripheral artery disease. The nurse observes that the left great toe is black. The discoloration is likely to result of: 1. atrophy 2. contraction 3. gangrene 4. rubor

Ans: 3. gangrene

A client with venous thrombus reports having pain in the legs. What should the nurse do first? 1. Elevate the foot of the bed 2. Elevate the legs by using a pillow under the knees 3. Encourage adequate fluid intake 4. Massage the lower legs

Ans: 1. Elevate the foot of the bed

A client is admitted with a 6.5 cm thoracic aneurysm. The nurse records findings from the initial assessment in the client's chart, BP 160/90, HR 74, Respirations 20. At 1030 the client has sharp midchest pain after having a bowel movement. What should the nurse do first? 1. assess the clients vital signs 2. administer pain medication as prescribed 3. assess the client's neurologic status 4. contact the HCP

1. assess the clients vital signs

A client with a recent diagnosis of deep vein thrombosis (DVT) has suddent onset of shortness of breath and chest pain that increases with a deep breath. The nurse should first: 1. assess the oxygen saturation 2. call the HCP 3. administer morphine sulfate, 2 mg IV. 4. perform range-of-motion exercises in the involved leg.

1. assess the oxygen saturation

A client is to have sclerotherapy to treat varicose veins. The nurse should instruct the client that this procedure 1. causes the veins to fade and disappear 2. ensures that variscosities will not appear again 3. requires a short hospitalization for complete recovery 4. result in bruising lasting for 2 weeks

1. causes the veins to fade and disappear

Which group is at greatest risk for Raynaud's phenomenon? 1. young women 2. old women 3. old men 4. young men

Ans: 1. young women

A client is receiving an IV infusion of 5% dextrose in water (D5W). The skin around the IV insertion site is red, warm to touch, and painful. The nurse should first: 1. administer aceptaminophen 2. change the D5W to normal saline 3. discontinue the IV 4. place a warm compress on the area

3. discontinue the IV

The nurse is caring for a client with vein thrombosis of the LLE. To prevent further tissue damage, it is important for the nurse to observe for which finding? 1. blood pressure and heart rate changes 2. gradual or acute loss of sensory and motor funciton 3. metabolic changes 4. swelling in the LLE

Ans: 2. gradual or acute loss of sensory and motor function

The nurse is assessing the lower extremities of the client with peripheral artery disease. Which findings are expected? Select all that apply. 1. hairy legs 2. mottled skin 3. pink skin 4. coolness 5. moist skin

Ans: 2. mottled skin 4. coolness

A sedentary, obese, middle-aged client is recovering from surgery to remove an embolus in the right iliac artery. The nurse should develop a discharge plan with the client that will focus on participating in which activities? Select all that apply. 1. aerobic activity 2. strength training 3. weight control 4. wearing supportive athletic shoes

Ans: 1. aerobic activity 3. weight control

A client has been diagnosed with Raynaud's phenomenon on the tip of the nose and fingertips. The HCP has prescribed reserpine to determine if the client will obtain relief. The client often works outside in cold weather and also smokes two pack of cigarettes per day. Which directions should be included in the discharge plan for this client? Select all that apply. 1. Stop smoking 2. Wear a face covering and gloves in the winter. 3. Place fingertips in cool water to rewarm them 4. Find employment that can be done in a warm environment 5. Report signs of orthostatic hypotension

Ans: 1. Stop smoking 2. Wear a face covering and gloves in the winter 5. Report signs of orthostatic hypotension

When giving discharge instructions to the client with Raynaud's phenomenon, the nurse should explain that the expected outcome of taking a beta-adrenergic blocking medication is to control the symptoms by 1. decreasing the influence of the symphathetic nervous system on the tissues in the hands and feet 2. decreasing the pain by producing analgesia 3. increasing the blood supply to the affected area 4. increasing monoamine oxidase

Ans: 1. decreasing the influence of the sympathetic nervous system on the tissues in the hands and feet

Which instructions should be included in the plan of care for a client who had a left femoral-popliteal bypass yesterday? Select all that apply. 1. Turn frequently, and use pillows to support the incision 2. Encourage the client to change positions frequently to prevent atelectasis 3. Place the left leg in a knee-flexed position to promote oxygenation 4. Place the client in supine position, and elevate the leg above the heart to prevent edema. 5. Encourage the client to maintain bed rest to prevent stress on suture line.

Ans: 1. Turn frequently, and use pillows to support the incision. 2. Encourage the client to change positions frequently to prevent atelectasis 5. Encourage the client to maintain bed rest to prevent stress on suture line.

The nurse is caring for a client with peripheral artery disease who has just returned from having a percutaneous transluminal balloon angioplasty. Which of these finding require immediate attention from the nurse. 1. a change in the intensity of the pulse from the baseline. 2. pain "2 out of 10" at the catheterization site 3. shiny skin and a hairless appearance on the affected leg 4. the presence of an ulcer on the limb of the catheterization site

Ans: 1. a change in the intensity of the pulse from the baseline

What instructions should the nurse give a client experiencing signs and symptoms related to decreased arterial insufficiency? Select all that apply. 1. Avoid smoking and exposure to the cold. 2. Take acetaminophen if experiencing pain at night. 3. Take aspirin or clopidogrel as prescribed. 4. Use additional bed clothes at night. 5. Wear tight socks to keep feet warm.

Ans: 1. Avoid smoking and exposure to the cold. 3. Take aspirin or clopidogrel as prescribed. 4. Use additional bed clothes at night.

The nurse is assessing a 48 year old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain the calf during exercises that disappears at rest. Which finding requires further evaluation? 1. heart rate 57 bpm 2. SpO2 of 94% on room air 3. blood pressure 134/82 mm Hg 4. ankle-brachial index of 0.65

Ans: 1. SpO2 of 94% on room air

The nurse is unable to palpate the client's left pedal pulses. What should the nurse do first? 1. Auscultate the pulses with a stethoscope. 2. Call the healthcare provider (HCP). 3. Use a doppler ultrasound device. 4. Inspect the lower left extremity.

Ans: 3. Use a doppler ultrasound device.

A client is discharged after an aortic aneurysm repair with a synthetic graft to replace part of the aorta. The nurse should instruct the client to notify the HCP before having 1. blood drawn 2. an IV line inserted 3. major dental work 4. an x-ray examination

3. major dental work

A client with Buerger's disease smokes two packs of cigarettes a day. When helping a client change smoking behavior. It is important to know the client's 1. ability to attend support groups 2. goals for the treatment 3. perception for the negative behavior 4. motivation

3. perception for the negative behavior

Which instructions should the nurse include when developing a teaching plan for a client being discharged from the hospital on anticoagulant therapy after having DVT? Select all that apply 1. Check urine for bright blood and a dark smoky color 2. Walk daily as a good exercise 3. Use garlic and ginger, which may decrease bleeding time 4. Perform foot/leg exercises and walking around the airplane cabin when on long flights 5. Prevent DVT because of risk of pulmonary emboli 6. Avoid surface bumps because the skin is prone to injury

1. Check urine for bright blood and a dark smoky color 2. Walk daily as a good exercise 4. Perform foot/leg exercises and walking around the airplane cabin when on long flights 5. Prevent DVT because of risk of pulmonary emboli 6. Avoid surface bumps because the skin is prone to injury

A client has had a stasis ulcer of the left ankle with 2+ pitting edema for 2 years. The client is taking chlorothiazide. The desired outcome of this drug for this client is: 1. improve capillary circulation 2. decreased blood pressure 3. wound healing 4. absence of infection

1. improve capillary circulation

A client has acute arterial occlusion. The HCP has prescribed IV heparin. Before starting the medication, the nurse should 1. review the blood coagulation laboratory values 2. test the client's stools for occult blood 3. count the client's apical pulse for 1 minute 4. check the 24 hr urine output record

1. review the blood coagulation laboratory values

A client with an enlarged abdominal aorta admitted to the emergency department has severe back pain, nausea, blood pressure of 90/40, HR 128, respirations 28. In which order from first to last should the nurse implement these prescription? All option must be used 1. Monitor intake and output 2. Establish an intravenous infusion 3. Administer pain medication 4. Insert a NG tube

2. Establish an intravenous infusion 4. Insert a NG tube 3. Administer pain medication 1. Monitor intake and output

The nurse is assessing a client with Buerger's disease. The nurse should determine if the client is experiencing: 1. Thickening of the intima and media of the artery. 2. Inflammation and fibrosis of arteries, veins, and nerves 3. Vasospasm lasting several minutes 4. Pain, pallor, and pulselessness

2. Inflammation and fibrosis of arteries, veins, and nerves

Knee-high sequential compression devices have been prescribed for a newly admitted client. The client reports new pain localized in the right calf area that is noted to be slightly reddened and warm to touch upon initial assessment. What should the nurse do first? 1. Offer analgesics as prescribed, and apply compression devices. 2. Leave the compression devices off, and contact the HCP to report any assessment findings. 3. Massage the area of discomfort before applying the compression devices. 4. Leave the compression devices off, and report assessment findings to the oncoming shift

2. Leave the compression devices off, and contact the HCP to report any assessment findings.

In preparation for being discharged to home, the nurse is teaching a client with a chronic right stasis ulcer about wound care. The client needs further teaching when the client states: "I will 1. make an appointment with a physical therapist." 2. apply a home herb mixture to the wound to promote healing." 3. be patient with the healing process." 4. eat a balanced diet."

2. apply a home herb mixture to the wound to promote healing."

A client is admitted to the emergency department with severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. The primary goal at this time is to 1. maintain circulation 2. manage pain 3. prepare the client for emergency surgery 4. teach postoperative breathing exercises

3. prepare the client for emergency surgery

The nurse is teaching a group of women about risk for varicose veins. Which client is at risk for varicose veins? 1. a client who has had a cerebrovascular accident 2. a client who has had anemia 3. a client who has had thrombophlebitis 4. a client who has had transient ischemic attacks

3. a client who has had thrombophlebitis

The nurse has received a change of shift about clients. Which client should the nurse assess first? 1. a client with chronic heart failure with right upper quadrant fullness 2. a client in atrial fibrillation with a heart rate of 90 with a "fluttering" feeling 3. a client with peripheral artery disease just returning from an angiogram 4. a client who had a coronary artery bypass surgery 2 days ago who reports having incisional pain of 3 out of 10

3. a client with peripheral artery disease just returning from an angiogram

The nurse is assessing a client who had an abdominal aortic aneurysm repair 2 hrs ago. Which finding warrants further evaluation? 1. absent bowel sounds and mild abdominal distention 2. a BUN of 26 mg/dL and creatinine of 1.2 mg/dL 3. an arterial BP of 80/50 mm Hg 4. +1 pedal pulses in bilateral lower extremities

3. an arterial BP of 80/50 mm Hg

A 45 year old client had a complete abdominal hysterectomy with bilateral salpingo-oophorectomy 2 days ago. The client's abdominal dressing is dry and intact. While sitting up in the chair, the client has severe pain and numbness in her left leg. The nurse should first: 1. administer pain medication 2. assess edema in the left leg 3. assess color and temperature of the left leg 4. encourage the client to change her position

3. assess color and temperature of the left leg

A client with a cerebral embolus is receiving streptokinase. The nurse should evaluate the client for which expected therapeutic outcomes of drug therapy? 1. improved cerebral perfusion 2. decreased vascular permeability 3. dissolved emboli 4. prevention of cerebral hemorrhage

3. dissolved emboli

A client with a history of hypertension and peripheral vascular artery disease underwent an aortobifemoral bypass graft. Preoperative medications include pentoxifylline, metoprolol, and furosemide. On postoperative day 1, the 1200 vitals are as follows: temperature 98.9 F, heart rate 132 bpm, respiratory rate 20 breaths/min, and blood pressure 126/78 mm Hg. Urine output is 50 to 70 mL/h. The hemoglobin and hematocrit are stable. The medications have not been prescribed for administration after surgery. Using the SBAR technique for communication, the nurse contacts the HCP and recommends to 1. continue the pentoxifylline 2. increase the IV fluids 3. restart the metoprolol 4. resume the fursomide

3. restart the metoprolol

A client with peripheral artery disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 mm Hg to 88/62 mm Hg. What should the nurse assess first? 1. IV fluid infusion rate 2. pedal pulses 3. nasal cannula flow rate 4. capillary refill

Ans: 2. pedal pulses

In order to prevent recurrent vasospastic episodes with Raynaud's phenomenon, what should the nurse instruct the client to do? 1. Keep the hands and feet elevated as much as possible. 2. Use a vibrating massage device on the hands. 3. Wear gloves when obtaining food from the refrigerator. 4. Increase coffee intake to two cups per day

Ans: 3. wear gloves when obtaining food from the refrigerator

The nurse is caring for a client with peripheral artery disease who has recently been prescribed clopidogrel. The nurse understands that more teaching is necessary when the client states: 1. "I should not be surprised if I bruise easier or if my gums bleed a little when brushing my teeth." 2. "It does not really matter if I take this medicine with or without food, whatever works best for my stomach." 3. "I should stop taking my medicine if it makes me feel weak and dizzy." 4. "The doctor prescribed this medicine to make my platelets less likely to stick together and help prevent clots from forming."

Ans: 3. "I should stop taking my medicine if it makes me feel weak and dizzy."

A 45-year-old client had a complete abdominal hysterectomy with bilateral salpingo-oophorectomy 2 days ago. The client's abdominal dressing is dry and intact. While sitting up in the chair, the client has severe pain and numbness in her left leg. The nurse should first 1. administer pain medication 2. assess edema in the left leg 3. assess color and temp of the left leg 4. encourage the client to change her position

Ans: 3. assess the color and temp of the left leg

A client with a cerebral embolus is receiving stretokinase. The nurse should evaluate the client for while therapeutic outcomes of this drug therapy? 1. improved cerebral perfusion 2. decreased vascular permability 3. dissolved emboli 4. prevention of cerebral hemorrhage

Ans: 3. dissolved emboli

When instructing a client who has been newly diagnosed with Raynaud's phenomenon about management of care, the nurse should discuss which topic? 1. scheduling a sympathectomy procedure for the next visit 2. using a beta-blocker medication 3. follow-up monitoring for development of connective tissue disease 4. benefit of an angioplasty to the affected extremities

Ans: 3. follow-up monitoring for development of connective tissue disease

A client is admitted for a revascularization procedure for artheriosclerosis in the left iliac artery. To promote circulation in the extremities, the nurse should: 1. position the client on a firm mattress. 2. keep the involved extremity warm with blankets. 3. position the left leg at or below the body's horizontal plane 4. encourage the client to raise and lower the leg four times every hour.

Ans: 3. position the leg at or below the body's horizontal plane.

A client with Raynauds' phenomenon is prescribed diltiazem. The intended outcome is 1. decreased heart rate 2. conversion to NSR 3. reduced episodes of finger numbness 4. increased SpO2

Ans: 3. reduced episodes of finger numbness

One goal is caring for a client with arterial occlusive disease is to promote vasodilation in the affected extremity. To achieve this goal, the nurse should encourage the client to: 1. avoid eating low-fat foods 2. elevate the legs above the heart 3. stop smoking 4. begin a jogging program

Ans: 3. stop smoking

The client with peripheral artery disease and a history of hypertension is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which should be the nurse's first step in planning the dietary instructions? 1. Determine the client's knowledge level about cholesterol. 2. Ask the client to name foods high in fat, cholesterol, and salt. 3. Explain the important of complying with the diet. 4. Assess the family's food preferences.

Ans: 4. Assess the family's food preferences.