Peripheral Vascular Disease
64. The client with varicose veins asks the nurse, "What caused me to have these?" Which statement by the nurse would be most appropriate? 1. "You have incompetent valves in your legs." 2. "Your legs have decreased oxygen to the muscle." 3. "There is an obstruction in the saphenous vein." 4. "Your blood is thick and can't circulate properly."
1
Assessment of a patient's peripheral IV site reveals that phlebitis has developed over the past several hours. Which intervention should the nurse implement first? a. Remove the patient's IV catheter. Correct b. Apply an ice pack to the affected area. c. Decrease the IV rate to 20 to 30 mL/hr. d. Administer prophylactic anticoagulants.
A
What medications should the nurse expect to include in the teaching plan to decrease the risk of cardiovascular events and death for PAD patients (select all that apply)? a Ramipril (Altace) b Cilostazol (Pletal) c Simvastatin (Zocor) d Clopidogrel (Plavix) e Warfarin (Coumadin) f Aspirin (acetylsalicylic acid)
ACD
Which clinical manifestations are seen in patients with either Buerger's disease or Raynaud's phenomenon (select all that apply)? a. Intermittent fevers b. Sensitivity to cold temperatures c. Gangrenous ulcers on fingertips d. Color changes of fingers and toes e. Episodes of superficial vein thrombosis
BCD
A 39-year-old woman with a history of smoking and oral contraceptive use is admitted with a venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory test should the nurse review to evaluate the expected effect of the heparin? a Platelet count b Activated clotting time (ACT) c International normalized ratio (INR) d Activated partial thromboplastin time (APTT)
D
15. The nurse is teaching the client diagnosed with arterial occlusive disease. Which interventions should the nurse include in the teaching? Select all that apply. 1. Wash legs and feet daily in warm water. 2. Apply moisturizing cream to feet. 3. Buy shoes in the morning hours only. 4. Do not wear any type of knee stocking. 5. Wear clean white cotton socks.
1
55. Which assessment data would warrant immediate intervention by the nurse? 1. The client diagnosed with DVT who complains of pain on inspiration. 2. The immobile client who has refused to turn for the last three (3) hours. 3. The client who had an open cholecystectomy who refuses to breathe deeply. 4. The client who has had an inguinal hernia repair who must void before discharge.
1
56. The client diagnosed with a DVT is on a heparin (an anticoagulant) drip at 1,400 units per hour, and Coumadin (warfarin sodium; also an anticoagulant) 5 mg twice a day. Which intervention should the nurse implement first? 1. Check the PTT and PT/INR. 2. Check with the HCP to see which drug should be discontinued. 3. Administer both medications. 4. Discontinue the heparin because the client is receiving Coumadin.
1
9. The client diagnosed with essential hypertension is taking a loop diuretic daily. Which assessment data would require immediate intervention by the nurse? 1. The telemetry reads normal sinus rhythm. 2. The client has a weight gain of 2 kg within 1 to 2 days. 3. The client's blood pressure is 148/92. 4. The client's serum potassium level is 4.5 mEq.
2
23. Which medication should the nurse expect the health-care provider to order for a client diagnosed with arterial occlusive disease? 1. An anticoagulant medication. 2. An antihypertensive medication. 3. An antiplatelet medication. 4. A muscle relaxant.
3
3. The health-care provider prescribes an ACE inhibitor for the client diagnosed with essential hypertension. Which statement is the most appropriate rationale for administering this medication? 1. ACE inhibitors prevent beta receptor stimulation in the heart. 2. This medication blocks the alpha receptors in the vascular smooth muscle. 3. ACE inhibitors prevent vasoconstriction and sodium and water retention. 4. ACE inhibitors decrease blood pressure by relaxing vascular smooth muscle.
3
30. Which assessment data would cause the nurse to suspect the client has atherosclerosis? 1. Change in bowel movements. 2. Complaints of a headache. 3. Intermittent claudication. 4. Venous stasis ulcers.
3
The nurse is admitting a 68-year-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication? a. Vitamin K b. Cobalamin c. Heparin sodium d. Protamine sulfate
A
The patient has CVI and a venous ulcer. The unlicensed assistive personnel (UAP) decides to apply compression stockings because that is what these patients always have ordered. What assessment by the nurse would cause the application of compression stockings to harm the patient? a Rest pain b High blood pressure c Elevated blood sugar d Dry, itchy, flaky skin
A
When the patient is being examined for venous thromboembolism (VTE) in the calf, what diagnostic test should the nurse expect to teach the patient about first? a Duplex ultrasound b Contrast venography c Magnetic resonance venography d Computed tomography venography
A
Which person should the nurse identify as having the highest risk for abdominal aortic aneurysm? a A 70-year-old male, with high cholesterol and hypertension Correct b A 40-year-old female with obesity and metabolic syndrome c A 60-year-old male with renal insufficiency who is physically inactive d A 65-year-old female with hyperhomocysteinemia and substance abuse
A
A 62-year-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral artery disease (PAD). The patient is a smoker and has a history of gout. What should the nurse focus her teaching on to prevent complications for this patient? a Gender b Smoking c Ethnicity d Co-morbidities
B
A 67-year-old man with peripheral artery disease is seen in the primary care clinic. Which symptom reported by the patient would indicate to the nurse that the patient is experiencing intermittent claudication? a Patient complains of chest pain with strenuous activity. b Patient says muscle leg pain occurs with continued exercise. c Patient has numbness and tingling of all his toes and both feet. d Patient states the feet become red if he puts them in a dependent position.
B
A 73-year-old man with dementia has a venous ulcer related to chronic venous insufficiency. The nurse should provide education on which type of diet for this patient and his caregiver? a Low-fat diet b High-protein diet c Calorie-restricted diet d High-carbohydrate diet
B
A patient is admitted to the hospital with a diagnosis of abdominal aortic aneurysm. Which signs and symptoms would suggest that his aneurysm has ruptured? a. Sudden shortness of breath and hemoptysis b. Sudden, severe low back pain and bruising along his flank c. Gradually increasing substernal chest pain and diaphoresis d. Sudden, patchy blue mottling on feet and toes and rest pain
B
A patient was just diagnosed with acute arterial ischemia in the left leg secondary to atrial fibrillation. Which early clinical manifestation must be reported to the physician immediately to save the patient's limb? a Paralysis b Paresthesia c Crampiness d Referred pain
B
The first priority of collaborative care of a patient with a suspected acute aortic dissection is to a. reduce anxiety. b. control blood pressure. c. monitor for chest pain. d. increase myocardial contractility.
B
The nurse is caring for a newly admitted patient with vascular insufficiency. The patient has a new order for enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to correctly administer this medication? a. Spread the skin before inserting the needle. b. Leave the air bubble in the prefilled syringe. c. Use the back of the arm as the preferred site. d. Sit the patient at a 30-degree angle before administration.
B
The patient at highest risk for venous thromboembolism (VTE) is a. a 62-year-old man with spider veins who is having arthroscopic knee surgery. b. a 32-year-old woman who smokes, takes oral contraceptives, and is planning a trip to Europe. c. a 26-year-old woman who is 3 days postpartum and received maintenance IV fluids for 12 hours during her labor. d. an active 72-year-old man at home recovering from transurethral resection of the prostate for benign prostatic hyperplasia.
B
The patient had aortic aneurysm repair. What priority nursing action will the nurse use to maintain graft patency? a Assess output for renal dysfunction. b Use IV fluids to maintain adequate BP. c Use oral antihypertensives to maintain cardiac output. d Maintain a low BP to prevent pressure on surgical site
B
Which are probable clinical findings in a person with an acute lower extremity VTE (select all that apply)? a. Pallor and coolness of foot and calf b. Mild to moderate calf pain and tenderness c. Grossly diminished or absent pedal pulses d. Unilateral edema and induration of the thigh e. Palpable cord along a superficial varicose vein
BD
A 32-year-old female is prescribed diltiazem (Cardizem) for Raynaud's phenomenon. To evaluate the patient's expected response to this medication, what is most important for the nurse to assess? a Improved skin turgor b Decreased cardiac rate c Improved finger perfusion d Decreased mean arterial pressure
C
A 50-year-old woman weighs 95 kg and has a history of tobacco use, high blood pressure, high sodium intake, and sedentary lifestyle. When developing an individualized care plan for her, the nurse determines that the most important risk factors for peripheral artery disease (PAD) that need to be modified are: a. weight and diet. b. activity level and diet. c. tobacco use and high blood pressure. d. sedentary lifestyle and high blood pressure.
C
A patient with infective endocarditis develops sudden left leg pain with pallor, paresthesia, and a loss of peripheral pulses. The nurse's initial action should be to a. elevate the leg to promote venous return. b. start anticoagulant therapy with IV heparin. c. notify the physician of the change in peripheral perfusion. d. place the bed in reverse Trendelenburg to promote perfusion.
C
A postoperative patient asks the nurse why the physician ordered daily administration of enoxaparin (Lovenox). Which reply by the nurse is most appropriate? a. "This medication will help prevent breathing problems after surgery, such as pneumonia." b. "This medication will help lower your blood pressure to a safer level, which is very important after surgery." c. "This medication will help prevent blood clots from forming in your legs until your level of activity, such as walking, returns to normal." d. "This medication is a narcotic pain medication that will help take away any muscle aches caused by positioning on the operating room table."
C
A male patient was admitted for a possible ruptured aortic aneurysm, but had no back pain. Ten minutes later his assessment includes the following: sinus tachycardia at 138, BP palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret this assessment about the patient's aneurysm? a Tamponade will soon occur. b The renal arteries are involved. c Perfusion to the legs is impaired. d He is bleeding into the abdomen.
D
In planning care and patient teaching for the patient with venous leg ulcers, the nurse recognizes that the most important intervention in healing and control of this condition is a. sclerotherapy. b. using moist environment dressings. c. taking horse chestnut seed extract daily. d. applying elastic compression stockings.
D
41. The client is admitted for surgical repair of an 8-cm abdominal aortic aneurysm. Which sign/symptom would make the nurse suspect the client has an expanding AAA? 1. Complaints of low back pain. 2. Weakened radial pulses. 3. Decreased urine output. 4. Increased abdominal girth.
1
38. Which medical treatment would be prescribed for the client with an AAA less than 3 cm? 1. Ultrasound every six (6) months. 2. Intravenous pyelogram yearly. 3. Assessment of abdominal girth monthly. 4. Repair of abdominal aortic aneurysm.
1
54. The nurse is caring for a client receiving heparin sodium via constant infusion. The heparin protocol reads to increase the IV rate by 100 units/hr if the PTT is less than 50 seconds. The current PTT level is 46 seconds. The heparin comes in 500 mL of D5W with 25,000 units of heparin added. The current rate on the IV pump is 18 mL/hr. At what rate should the nurse set the pump? _________
20 mL/hr
16. Which assessment data would warrant immediate intervention in the client diagnosed with arterial occlusive disease? 1. The client has 2+ pedal pulses. 2. The client is able to move the toes. 3. The client has numbness and tingling. 4. The client's feet are red when standing.
3
A female patient with critical limb ischemia has had peripheral artery bypass surgery to improve her circulation. What care should the nurse provide on postoperative day 1? a Keep the patient on bed rest. b Assist the patient with walking several times. c Have the patient sit in the chair several times. d Place the patient on her side with knees flexed.
B
A nurse is caring for a patient with a diagnosis of deep venous thrombosis (DVT). The patient has an order to receive 30 mg enoxaparin (Lovenox). Which injection site should the nurse use to administer this medication safely? a. Buttock, upper outer quadrant b. Abdomen, anterior-lateral aspect c. Back of the arm, 2 inches away from a mole d. Anterolateral thigh, with no scar tissue nearby
B
A 40-year-old man tells the nurse he has a diagnosis for the color and temperature changes of his limbs but can't remember the name of it. He says he must stop smoking and avoid trauma and exposure of his limbs to cold temperatures to get better. This description should allow the nurse to ask the patient if he has which diagnosis? a Buerger's disease b Venous thrombosis c Acute arterial ischemia d Raynaud's phenomenon
A
A key aspect of teaching for the patient on anticoagulant therapy includes which instructions? a. Monitor for and report any signs of bleeding. b. Do not take acetaminophen (Tylenol) for a headache. c. Decrease your dietary intake of foods containing vitamin K. d. Arrange to have blood drawn routinely to check drug levels.
A
The nurse is reviewing the laboratory test results for a 68-year-old patient whose warfarin (Coumadin) therapy was terminated during the preoperative period. The nurse concludes that the patient is in the most stable condition for surgery after noting which INR (international normalized ratio) result? a. 1.0 b. 1.8 c. 2.7 d. 3.4
A
The patient reports tenderness when she touches her leg over a vein. The nurse assesses warmth and a palpable cord in the area. The nurse knows the patient needs treatment to prevent which sequelae? a Pulmonary embolism b Pulmonary hypertension c Post-thrombotic syndrome d Venous thromboembolism
D
The recommended treatment for an initial VTE in an otherwise healthy person with no significant co-morbidities would include a. IV argatroban (Acova) as an inpatient. b. IV unfractionated heparin as an inpatient. c. subcutaneous unfractionated heparin as an outpatient. d. subcutaneous low-molecular-weight heparin as an outpatient.
D
What is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)? a. Application of topical antibiotics to venous ulcers b. Maintaining the patient's legs in a dependent position c. Administration of oral and/or subcutaneous anticoagulants d. Teaching the patient the correct use of compression stockings
D
67. The 80-year-old client is being discharged home after having surgery to débride a chronic venous ulcer on the right ankle. Which referral would be most appropriate for the client? 1. Occupational therapist. 2. Social worker. 3. Physical therapist. 4. Cardiac rehabilitation.
2
10. The client diagnosed with essential hypertension asks the nurse, "I don't know why the doctor is worried about my blood pressure. I feel just great." Which statement by the nurse would be the most appropriate response? 1. "Damage can be occurring to your heart and kidneys even if you feel great." 2. "Unless you have a headache, your blood pressure is probably within normal limits." 3. "When is the last time you saw your doctor? Does he know you are feeling great?" 4. "Your blood pressure reflects how well your heart is working."
1
17. Which client problem would be priority in a client diagnosed with arterial occlusive disease who is admitted to the hospital with a foot ulcer? 1. Impaired skin integrity. 2. Activity intolerance. 3. Ineffective health maintenance. 4. Risk for peripheral neuropathy.
1
19. The nurse is unable to assess a pedal pulse in the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement first? 1. Complete a neurovascular assessment. 2. Use the Doppler device. 3. Instruct the client to hang the feet off the side of the bed. 4. Wrap the legs in a blanket.
1
21. The nurse is assessing the client diagnosed with long-term arterial occlusive disease. Which assessment data support the diagnosis? 1. Hairless skin on the legs. 2. Brittle, flaky toenails. 3. Petechiae on the soles of feet. 4. Nonpitting ankle edema.
1
29. The nurse is discussing the pathophysiology of atherosclerosis with a client who has a normal high-density lipoprotein (HDL) level. Which information should the nurse discuss with the client concerning HDL? 1. A normal HDL is good because it has a protective action in the body. 2. HDL lipoprotein level measures the free fatty acids and glycerol in the blood. 3. HDLs are the primary transporters of cholesterol into the cell. 4. The client needs to decrease the amount of cholesterol and fat in the diet.
1
32. The nurse is discussing the importance of exercising with a client who is diagnosed with CAD. Which statement best describes the scientific rationale for encouraging 30 minutes of walking daily to help prevent complications of atherosclerosis? 1. Exercise promotes the development of collateral circulation. 2. Isometric exercises help develop the client's muscle mass. 3. Daily exercise helps prevent plaque from developing in the vessel. 4. Isotonic exercises promote the transport of glucose into the cell.
1
43. The client had an abdominal aortic aneurysm repair two (2) days ago. Which intervention should the nurse implement first? 1. Assess the client's bowel sounds. 2. Administer an IV prophylactic antibiotic. 3. Encourage the client to splint the incision. 4. Ambulate the client in the room with assistance.
1
46. Which assessment data would require immediate intervention by the nurse for the client who is six (6) hours postoperative abdominal aortic aneurysm repair? 1. Absent bilateral pedal pulses. 2. Complaints of pain at the site of the incision. 3. Distended, tender abdomen. 4. An elevated temperature of 100˚F.
1
47. The nurse is discussing discharge teaching with the client who is three (3) days postoperative abdominal aortic aneurysm repair. Which discharge instructions should the nurse include when teaching the client? 1. Notify HCP of any redness or irritation of the incision. 2. Do not lift anything that weighs more than 20 pounds. 3. Inform client there may be pain not relieved with pain medication. 4. Stress the importance of having daily bowel movements.
1
50. The nurse is caring for clients on a surgical floor. Which client should be assessed first? 1. The client who is four (4) days postoperative abdominal surgery and is complaining of left calf pain when ambulating. 2. The client who is one (1) day postoperative hernia repair who has just been able to void 550 mL of clear amber urine. 3. The client who is five (5) days postoperative open cholecystectomy who has a T-tube and is being discharged. 4. The client who is 16 hours post-abdominal hysterectomy and is complaining of abdominal pain and is expelling flatus.
1
62. Which assessment data would support that the client has a venous stasis ulcer? 1. A superficial pink open area on the medial part of the ankle. 2. A deep pale open area over the top side of the foot. 3. A reddened blistered area on the heel of the foot. 4. A necrotic gangrenous area on the dorsal side of the foot.
1
66. The unlicensed assistive personnel (UAP) is caring for the client diagnosed with chronic venous insufficiency. Which action would warrant immediate intervention from the nurse? 1. Removing compression stockings before assisting the client to bed. 2. Taking the client's blood pressure manually after using the machine. 3. Assisting the client by opening the milk carton on the lunch tray. 4. Calculating the client's shift intake and output with a pen and paper.
1
69. Which client would be most at risk for developing varicose veins? 1. A Caucasian female who is a nurse. 2. An African American male who is a bus driver. 3. An Asian female with no children. 4. An elderly male with diabetes.
1
8. The nurse is teaching the Dietary Approaches to Stop Hypertension (DASH) diet to a client diagnosed with essential hypertension. Which statement indicates that the client understands teaching concerning the DASH diet? 1. "I should eat at least four (4) to five (5) servings of vegetables a day." 2. "I should eat meat that has a lot of white streaks in it." 3. "I should drink no more than two (2) glasses of whole milk a day." 4. "I should decrease my grain intake to no more than twice a week."
1
Atherosclerosis 25. The nurse is teaching a class on coronary artery disease. Which modifiable risk factor should the nurse discuss when teaching about atherosclerosis? 1. Stress. 2. Age. 3. Gender. 4. Family history.
1
35. Which interventions should the nurse discuss with the client diagnosed with atherosclerosis? Select all that apply. 1. Include the significant other in the discussion. 2. Stop smoking or using any type of tobacco products. 3. Maintain a sedentary lifestyle as much as possible. 4. Avoid stressful situations. 5. Daily isometric exercises are important.
12
45. The client is diagnosed with a small abdominal aortic aneurysm. Which interventions should be included in the discharge teaching? Select all that apply. 1. Tell the client to exercise three (3) times a week for 30 minutes. 2. Encourage the client to eat a low-fat, low-cholesterol diet. 3. Instruct the client to decrease tobacco use. 4. Discuss the importance of losing weight with the client. 5. Teach the client to wear a truss at all times.
12
72. The nurse is completing a neurovascular assessment on the client with chronic venous insufficiency. What should be included in this assessment? Select all that apply. 1. Assess for paresthesia. 2. Assess for pedal pulses. 3. Assess for paralysis. 4. Assess for pallor. 5. Assess for polar.
1234
11. The intensive care department nurse is calculating the total intake for a client diagnosed with hypertensive crisis. The client has received 880 mL of D5W, IVPB of 100 mL of 0.9% NS, 8 ounces of water, 4 ounces of milk, and 6 ounces of chicken broth. The client has had a urinary output of 1,480 mL. What is the total intake for this client? _______
1520 mL
70. The client with varicose veins is six (6) hours postoperative vein ligation. Which nursing intervention should the nurse implement first? 1. Assist the client to dangle the legs off the side of the bed. 2. Assess and maintain pressure bandages on the affected leg. 3. Apply a sequential compression device to the affected leg. 4. Administer the prescribed prophylactic intravenous antibiotic.
2
1. The 66-year-old male client has his blood pressure (BP) checked at a health fair. The BP is 168/98. Which action should the nurse implement first? 1. Recommend that the client have his blood pressure checked in one (1) month. 2. Instruct the client to see his health-care provider as soon as possible. 3. Discuss the importance of eating a low-salt, low-fat, low-cholesterol diet. 4. Explain that this BP is within the normal range for an elderly person.
2
12. The nurse is teaching a class on arterial essential hypertension. Which modifiable risk factors would the nurse include when preparing this presentation? 1. Include information on retinopathy and nephropathy. 2. Discuss sedentary lifestyle and smoking cessation. 3. Include discussions on family history and gender. 4. Provide information on a low-fiber and high-salt diet.
2
13. The client comes to the clinic complaining of muscle cramping and pain in both legs when walking for short periods of time. Which medical term would the nurse document in the client's record? 1. Peripheral vascular disease. 2. Intermittent claudication. 3. Deep vein thrombosis. 4. Dependent rubor.
2
2. The nurse is teaching the client recently diagnosed with essential hypertension. Which instruction should the nurse provide when discussing exercise? 1. Walk at least 30 minutes a day on flat surfaces. 2. Perform light weight lifting three (3) times a week. 3. Recommend high-level aerobics daily. 4. Encourage the client to swim laps once a week.
2
20. The wife of a client with arterial occlusive disease tells the nurse, "My husband says he is having rest pain. What does that mean?" Which statement by the nurse would be most appropriate? 1. "It describes the type of pain he has when he stops walking." 2. "His legs are deprived of oxygen during periods of inactivity." 3. "You are concerned that your husband is having rest pain." 4. "This term is used to support that his condition is getting better."
2
28. The client tells the nurse that his cholesterol level is 240 mg/dL. Which action should the nurse implement? 1. Praise the client for having a normal cholesterol level. 2. Explain that the client needs to lower the cholesterol level. 3. Discuss dietary changes that could help increase the level. 4. Allow the client to ventilate feelings about the blood test result.
2
33. The HCP prescribes an HMG-CoA reductase inhibitor (statin) medication to a client with CAD. Which should the nurse teach the client about this medication? 1. Take this medication on an empty stomach. 2. This medication should be taken in the evening. 3. Do not be concerned if muscle pain occurs. 4. Check your cholesterol level daily.
2
36. The nurse is caring for clients on a telemetry floor. Which nursing task would be most appropriate to delegate to an unlicensed assistive personnel (UAP)? 1. Teach the client how to perform a glucometer check. 2. Assist feeding the client diagnosed with congestive heart failure. 3. Check the cholesterol level for the client diagnosed with atherosclerosis. 4. Assist the nurse to check the unit of blood at the client's bedside.
2
4. The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which intervention should the nurse implement? 1. Notify the health-care provider if the potassium level is 3.8 mEq. 2. Question administering the medication if the BP is <90/60 mm Hg. 3. Do not administer the medication if the client's radial pulse is >100. 4. Monitor the client's BP while he or she is lying, standing, and sitting.
2
40. The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment? 1. "I have stomach pain every time I eat a big, heavy meal." 2. "I don't have any abdominal pain or any type of problems." 3. "I have periodic episodes of constipation and then diarrhea." 4. "I belch a lot, especially when I lay down after eating."
2
42. The client is one (1) day postoperative abdominal aortic aneurysm repair. Which information from the unlicensed assistive personnel (UAP) would require immediate intervention from the nurse? 1. The client refuses to turn from the back to the side. 2. The client's urinary output is 90 mL in six (6) hours. 3. The client wants to sit on the side of the bed. 4. The client's vital signs are T 98, P 90, R 18, and BP 130/70.
2
44. Which health-care provider's order should the nurse question in a client diagnosed with an expanding abdominal aortic aneurysm who is scheduled for surgery in the morning? 1. Type and crossmatch for two (2) units of blood. 2. Tap water enema until clear fecal return. 3. Bedrest with bathroom privileges. 4. Keep NPO after midnight.
2
52. The nurse and an unlicensed assistive personnel (UAP) are bathing a bedfast client. Which action by the UAP warrants immediate intervention? 1. The UAP closes the door and cubicle curtain before undressing the client. 2. The UAP begins to massage and rub lotion into the client's calf. 3. The UAP tests the temperature of the water with the wrist before starting. 4. The UAP collects all the linens and supplies and brings them to the room.
2
57. Which actions should the surgical scrub nurse take to prevent personally developing a DVT? 1. Keep the legs in a dependent position and stand as still as possible. 2. Flex the leg muscles and change the leg positions frequently. 3. Wear white socks and shoes that have a wedge heel. 4. Ask the surgeon to allow the nurse to take a break midway through each surgery.
2
6. The nurse just received the a.m. shift report. Which client should the nurse assess first? 1. The client diagnosed with coronary artery disease who has a BP of 170/100. 2. The client diagnosed with deep vein thrombosis who is complaining of chest pain. 3. The client diagnosed with pneumonia who has a pulse oximeter reading of 98%. 4. The client diagnosed with ulcerative colitis who has nonbloody diarrhea.
2
65. The nurse is caring for the client with chronic venous insufficiency. Which statement indicates the client understands the discharge teaching? 1. "I shouldn't cross my legs for more than 15 minutes." 2. "I need to elevate the foot of my bed while sleeping." 3. "I should take a baby aspirin every day with food." 4. "I should increase my fluid intake to 3,000 mL a day."
2
Abdominal Aortic Aneurysm 37. Which assessment data would the nurse recognize to support the diagnosis of abdominal aortic aneurysm (AAA)? 1. Shortness of breath. 2. Abdominal bruit. 3. Ripping abdominal pain. 4. Decreased urinary output.
2
53. The client diagnosed with a DVT is placed on a medical unit. Which nursing interventions should be implemented? Select all that apply. 1. Place sequential compression devices on both legs. 2. Instruct the client to stay in bed and not ambulate. 3. Encourage fluids and a diet high in roughage. 4. Monitor IV site every 4 hours and PRN. 5. Assess Homans' sign every 24 hours.
234
14. Which instruction should the nurse include when providing discharge instructions to a client diagnosed with peripheral arterial disease? 1. Encourage the client to use a heating pad on the lower extremities. 2. Demonstrate to the client the correct way to apply elastic support hose. 3. Instruct the client to walk daily for at least 30 minutes. 4. Tell the client to check both feet for red areas at least once a week.
3
31. The nurse is teaching a class on atherosclerosis. Which statement describes the scientific rationale as to why diabetes is a risk factor for developing atherosclerosis? 1. Glucose combines with carbon monoxide, instead of with oxygen, and this leads to oxygen deprivation of tissues. 2. Diabetes stimulates the sympathetic nervous system, resulting in peripheral constriction that increases the development of atherosclerosis. 3. Diabetes speeds the atherosclerotic process by thickening the basement membrane of both large and small vessels. 4. The increased glucose combines with the hemoglobin, which causes deposits of plaque in the lining of the vessels.
3
34. The nurse knows the client understands the teaching concerning a low-fat, low- cholesterol diet when the client selects which meal? 1. Fried fish, garlic mashed potatoes, and iced tea. 2. Ham and cheese on white bread and whole milk. 3. Baked chicken, baked potato, and skim milk. 4. A hamburger, French fries, and carbonated beverage.
3
39. Which client would be most likely to develop an abdominal aortic aneurysm? 1. A 45-year-old female with a history of osteoporosis. 2. An 80-year-old female with congestive heart failure. 3. A 69-year-old male with peripheral vascular disease. 4. A 30-year-old male with a genetic predisposition to AAA.
3
49. The nurse is discharging a client diagnosed with DVT from the hospital. Which discharge instructions should be provided to the client? 1. Have the PTT levels checked weekly until therapeutic range is achieved. 2. Staying at home is best, but if traveling, airplanes are better than automobiles. 3. Avoid green leafy vegetables and notify the HCP of red or brown urine. 4. Wear knee stockings with an elastic band around the top.
3
58. The client receiving low molecular weight heparin (LMWH) subcutaneously to prevent DVT following hip replacement surgery complains to the nurse that there are small purple hemorrhaged areas on the upper abdomen. Which action should the nurse implement? 1. Notify the HCP immediately. 2. Check the client's PTT level. 3. Explain this results from the medication. 4. Assess the client's vital signs.
3
59. The home health nurse is admitting a client diagnosed with a DVT. Which action by the client warrants immediate intervention by the nurse? 1. The client takes a stool softener every day at dinnertime. 2. The client is wearing a Medic Alert bracelet. 3. The client takes vitamin E over-the-counter medication. 4. The client has purchased a new recliner that will elevate the legs.
3
60. The client is being admitted with Coumadin (warfarin, an anticoagulant) toxicity. Which laboratory data should the nurse monitor? 1. Blood urea nitrogen (BUN) levels. 2. Bilirubin levels. 3. International normalized ratio (INR). 4. Partial thromboplastin time (PTT).
3
7. The client diagnosed with essential hypertension asks the nurse, "Why do I have high blood pressure?" Which response by the nurse would be most appropriate? 1. "You probably have some type of kidney disease that causes the high BP." 2. "More than likely you have had a diet high in salt, fat, and cholesterol." 3. "There is no specific cause for hypertension, but there are many known risk factors." 4. "You are concerned that you have high blood pressure. Let's sit down and talk."
3
71. The nurse has just received the a.m. shift report. Which client would the nurse assess first? 1. The client with a venous stasis ulcer who is complaining of pain. 2. The client with varicose veins who has dull aching muscle cramps. 3. The client with arterial occlusive disease who cannot move the foot. 4. The client with deep vein thrombosis who has a positive Homans' sign.
3
Peripheral Venous Disease 61. The nurse is teaching a class on venous insufficiency. The nurse would identify which condition as the most serious complication of chronic venous insufficiency? 1. Arterial thrombosis. 2. Deep vein thrombosis. 3. Venous ulcerations. 4. Varicose veins.
3
18. The client diagnosed with arterial occlusive disease is one (1) day postoperative right femoral-popliteal bypass. Which intervention should the nurse implement? 1. Keep the right leg in the dependent position. 2. Apply sequential compression devices to lower extremities. 3. Monitor the client's pedal pulses every shift. 4. Assess the client's leg dressing every four (4) hours.
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22. The health-care provider ordered a femoral angiogram for the client diagnosed with arterial occlusive disease. Which intervention should the nurse implement? 1. Explain that this procedure will be done at the bedside. 2. Discuss with the client that he or she will be on bedrest with bathroom privileges. 3. Inform the client that no intravenous access will be needed. 4. Inform the client that fluids will be increased after the procedure.
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24. The nurse and an unlicensed assistive personnel (UAP) are caring for a 64-year-old client who is four (4) hours postoperative bilateral femoral-popliteal bypass surgery. Which nursing task should be delegated to the UAP? 1. Monitor the continuous passive motion machine. 2. Assist the client to the bedside commode. 3. Feed the client the evening meal. 4. Elevate the foot of the client's bed.
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26. The client asks the nurse, "My doctor just told me that atherosclerosis is why my legs hurt when I walk. What does that mean?" Which response by the nurse would be the best response? 1. "The muscle fibers and endothelial lining of your arteries have become thickened." 2. "The next time you see your HCP, ask what atherosclerosis means." 3. "The valves in the veins of your legs are incompetent so your legs hurt." 4. "You have a hardening of your arteries that decreases the oxygen to your legs."
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27. The client diagnosed with peripheral vascular disease is overweight, has smoked two (2) packs of cigarettes a day for 20 years, and sits behind a desk all day. What is the strongest factor in the development of atherosclerotic lesions? 1. Being overweight. 2. Sedentary lifestyle. 3. High-fat, high-cholesterol diet. 4. Smoking cigarettes.
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5. The male client diagnosed with essential hypertension has been prescribed an alphaadrenergic blocker. Which intervention should the nurse discuss with the client? 1. Eat at least one (1) banana a day to help increase the potassium level. 2. Explain that impotence is an expected side effect of the medication. 3. Take the medication on an empty stomach to increase absorption. 4. Change position slowly when going from lying to sitting position.
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51. The male client is diagnosed with Guillain-Barré (GB) syndrome and is in the intensive care unit on a ventilator. Which cardiovascular rationale explains implementing passive range-of-motion (ROM) exercises? 1. Passive ROM exercises will prevent contractures from developing. 2. The client will feel better if he is able to exercise and stretch his muscles. 3. ROM exercises will help alleviate the pain associated with GB syndrome. 4. They help to prevent DVTs by movement of the blood through the veins.
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63. The client is employed in a job that requires extensive standing. Which intervention should the nurse include when discussing how to prevent varicose veins? 1. Wear low-heeled, comfortable shoes. 2. Wear clean white cotton socks. 3. Move the legs back and forth often. 4. Wear graduated compression hose.
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68. Which assessment data would the nurse expect to find in the client diagnosed with chronic venous insufficiency? 1. Decreased pedal pulses. 2. Cool skin temperature. 3. Intermittent claudication. 4. Brown discolored skin.
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A patient with varicose veins has been prescribed compression stockings. How should the nurse teach the patient to use these? a. "Try to keep your stockings on 24 hours a day, as much as possible." b. "While you're still lying in bed in the morning, put on your stockings." c. "Dangle your feet at your bedside for 5 minutes before putting on your stockings." d. "Your stockings will be most effective if you can remove them for a few minutes several times a day."
B
Priority nursing measures after an abdominal aortic aneurysm repair include a. assessment of cranial nerves and mental status. b. administration of IV heparin and monitoring of aPTT. c. administration of IV fluids and monitoring of kidney function. d. elevation of the legs and application of elastic compression stockings
C
Rest pain is a manifestation of PAD that occurs due to a chronic a. vasospasm of small cutaneous arteries in the feet. b. increase in retrograde venous blood flow in the legs. c. decrease in arterial blood flow to the nerves of the feet. d. decrease in arterial blood flow to the leg muscles during exercise.
C
The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed? a. Decreased cardiac output b. Increased blood pressure c. Cerebral or pulmonary emboli d. Excessive bleeding from incision or IV sites
C
The nurse is caring for a preoperative patient who has an order for vitamin K by subcutaneous injection. The nurse should verify that which laboratory study is abnormal before administering the dose? a. Hematocrit (Hct) b. Hemoglobin (Hgb) c. Prothrombin time (PT) d. Partial thromboplastin time (PTT)
C
The nurse would determine that a postoperative patient is not receiving the beneficial effects of enoxaparin (Lovenox) after noting what during a routine shift assessment? a. Generalized weakness and fatigue b. Crackles bilaterally in the lung bases c. Pain and swelling in lower extremity d. Abdominal pain with decreased bowel sounds
C
The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT). The patient now needs to undergo surgery for appendicitis. The nurse is reviewing the laboratory results for this patient before administering an ordered dose of vitamin K. The nurse determines that the medication is both safe to give and is most needed when the international normalized ratio (INR) is which result? a. 1.0 b. 1.2 c. 1.6 d. 2.2
D
The nurse is preparing to administer a scheduled dose of enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to administer this medication correctly? a. Remove the air bubble in the prefilled syringe. b. Aspirate before injection to prevent IV administration. c. Rub the injection site after administration to enhance absorption. d. Pinch the skin between the thumb and forefinger before inserting the needle
D
