Unit 3 HC2A

The nurse is monitoring a client receiving treatment for hypertension. Which BP reading indicates to the nurse that the treatment is successful? 1. 118/78 2. 154/80 3. 190/100 4. 136/96

1. 118/78

The nurse assesses the lab values of a client having an annual physical exam. Which lab value indicates that further assessment is necessary? 1. A blood cholesterol level of 260 mg/dl 2. A blood glucose level of 100 mg/dl 3. A hemoglobin level of 15 g/dL 4. A potassium level of 4.8 mEq/L

1. A blood cholesterol level of 260 mg/dL

Which risk factor does the nurse MOST likely to contribute to an elevation of a clients BP? 1. A high-pressure job 2. Consumption of whole grains with each meal 3. One glass of red wine per day 4. Walking daily

1. A high-pressure job

The nurse provides care for a client diagnosed with a myocardial infarction. The clients adult child asks the nurse, "What is a realistic goal for my cardiovascular health?" Which is the BEST response by the nurse? 1. A total blood cholesterol level of less than 200 mg/dL 2. A body mass index between 25-30 3. A waist circumference of 41 inches 4. A BP of 90 mm Hg diastolic

1. A total blood cholesterol level of less than 200 mg/dL

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? SATA 1. Aerobic activity 2. Strength training 3. Weight control 4. Stress management 5. Wearing supportive athletic shoes

1. Aerobic activities 3. Weight control

An obese client taking Warfarin has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? SATA 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 5. Use an electric razor to shave

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

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

1. Apply the elastic stockings before getting out of bed 3. Remove the stockings every 8 hours, elevate the feet and reapply in 15 minutes

The nurse monitors a client diagnosed with hypertension. The client tells the nurse, "I have hypertension, but I haven't been taking my medications. I never refilled any of my prescriptions." Based on this information, how does the nurse intervene? 1. Assess the clients understanding of the importance of follow-up care and adhering to the medication regimen. 2. Instruct the client to go to the health care provider immediately for re-evaluation 3. Instructs the client about a low sodium diet since the client is not taking the medication 4. Insists the client go to the emergency department for a full evaluation.

1. Assesses the clients understanding of the importance of follow-up care and adhering to the medication regimen.

What instructions should the nurse give a client experiencing s/s related to decreased arterial insufficiency? SATA 1. Avoid smoking and exposure to the cold. 2. Take acetaminophin if experiencing pain at night. 3. Take asprin or clopidogrel as prescribed 4. Use additional bed clothes at night 5. Wear tight socks to keep feet warm

1. Avoid smoking and exposure to the cold 3. Take Asprin or Clopidogrel as prescribed 4. Use additional clothes at night

A client arrives in the emergency department reporting severe pain in the left leg that is not relieved by rest or medication. On physical exam, the nurse is MOST likely to assess which symptom? 1. Cold, mottled leg 2. Strong popliteal pulse 3. Edematous leg 4. Hot, reddened leg

1. Cold, mottled leg

The nurse provides care for a client receiving both Digoxin and Hydrochlorothiazide. The nurse understands a major adverse effect of Hydrochlorothiazide includes the following. 1. Hypokalemia 2. Hyperkalemia 3. Hyponatremia 4. Oliguria

1. Hypokalemia- Thiazide diuretics block reabsorption of Na+ and increase the excretion of water and K+ from the body, which can result in Hypokalemia.

The nurse provides discharge instructions to a client diagnosed with a large venous stasis ulcer. Which client statement indicates to the nurse that the client understands the discharge instructions? 1. Keep a compression bandage on the ulcer is the most important thing to do to help it heal 2. I need to keep my leg lower than the level of my heart to promote blood flow for healing. 3. I must remember to put on my antibiotic ointment two times a day or the ulcer won't heal. 4. Keeping my legs propped up isn't healthy because the infection will drain into my circulation

1. Keep a compression bandage on the ucler is the most important thing to do to help it heal. - A compression bandage provides extrinsic force to the muscles, stimulating contraction, and therefore exerting pressure on the veins and promoting venous flow.

A client with peripheral artery disease has femoral-popliteal bypass surgery. What goal should the nurse establish with the client immediately after surgery. 1. Maintain circulation 2. Prevent infection 3. Relieve pain 4. Provide education

1. Maintain circulation

The health care provider prescribes Captopril for a client diagnosed with hypertension. Before administering the first dose, it is MOST important for the nurse to make which statement? 1. Remain in bed for the first three hours after taking the first dose of medication 2. You may experience a loss of taste 3. You may experience hair loss. 4. You should increase your intake of fresh vegetables, fruit, and whole grains.

1. Remain in bed for the first three hours after taking the first dose of medication. - it is a ACE inhibitor that has a potent effect with the first dose.

A client who weighs 350 pounds is admitted to the medical floor. Which information MUST the nurse obtain to ensure an accurate BP reading from the clients right arm? 1. The circumference of the clients arm. 2. The previous BP readings 3. The clients exact weight in kg 4. The presence of pulses in the extremities.

1. The circumference of the clients arm.

The nurse assesses the cardiac status of a client and identifies an increased pulse pressure. Which is the BEST definition for the nurse to recall when providing education regarding this phenomenon? 1. The difference between systolic and diastolic BP readings 2. The intensity of peripheral pulses 3. The difference between the apical and radial pulses 4. The volume of the stoke and the heart rate

1. The difference between systolic and diastolic BP readings

The nurse provides care for a client diagnosed with a left hip fracture that has been repaired. The nurse understands which signs indicate a complication of long-term immobility? 1. Unilateral edema 2. +2 posterior tibialis 3. Dorsiflextion 4. 1 second capillary refill

1. Unilateral edema- edema indicates swelling from impaired venous return due to a venous thrombosis.

The nurse is caring for a client with peripheral artery disease who has just returned from having a percutaneous trasluminal balloon angio-plasty. Which of these findings 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. skiny skin and a hairless appearance on the affected leg 4. the presence of an ulcer on the limb of the catheterization site

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

The nurse teaches a class about hypertension at a health fair. Which statement BEST describes why a person diagnosed with hypertension should not smoke. 1. Smoking causes the arteries to constrict 2. The tars in smoke causes changes in lung tissue 3. The lungs are damaged by smoking 4. Smoking residues build up in the bladder.

1. smoking causes the arteries to constrict.

The nurse provides care for a client diagnosed with hypertension. The client states, "I no longer have headaches, so my BP must be normal now." Which is the BEST response for the nurse to give? 1. "If you no longer have headaches, then your BP probably is normal." 2. "High BP is usually asymptomatic and symptoms do not reliably indicate BP levels." 3. "Since you have lost weight, your BP is probably lower." 4. "It is good to avoid strenuous exercise to keep your BP lower."

2. "High BP is usually asymptomatic and symptoms do not reliably indicate BP levels.

The nurse teaches a client receiving an antihypertensive medication prior to discharge. The nurse determines the FURTHER teaching is necessary when the client makes which statement? 1. "I should check with my health provider before taking OTC medications." 2. "I can stop taking the medication when my BP goes down." 3. "I will follow up with my HCP to monitor my progress." 4. "I will change my positions slowly."

2. "I can stop taking the medication when my BP goes down."

The nurse performs BP screenings at a community center. The nurse knows which BP reading indicates stage 1 hypertension? 1. 160./110 mm Hg 2. 130/88 mm Hg 3. 128/78 mm Hg 4. 136/94 mm Hg

2. 130/88 mm Hg - hypertension stage 1 is present if the systolic pressure is within 130-139 mm Hg or the diastolic pressure is within 80-89 mm Hg.

The nurse provides care for a client in Buck traction awaiting repair of a fractured left femoral neck. The client reports pain in the left calf. The nurse notes the calf area is warm and red. The nurse identifies these symptoms as being caused by which pathology? 1. The fractured bone. 2. A possible circulatory complication 3. Skin irritation from skin traction 4. Infection from skeletal pin insertion sites.

2. A possible circulatory compliaction

The nurse provides care for a client with hypertension and notes that clients serum renin levels are increased. Which finding BEST describes the effect of increased renin levels on BP? 1. Decreases serum angiotensin II levels 2. Increases reabsorption of Na+ in kidneys 3. Increases myocardial contractability 4. Activates the sympathetic nervous system

2. Increases reabsorption of Na+ in kidneys

A client is scheduled to have an arteriogram. During the arteriogram the client reports having nausea, tingling, and dyspnea. What should the nurse do first? 1. administer epinephrine 2. inform the health care provider 3. administer O2 4. Inform the client that the procedure is almost done.

2. Inform the health care provider

The nurse provides care for a client diagnosed with chronic venous insufficiency. Which PRIORITY intervention does the nurse include when planning the clients care? 1. Administer heparin IV at 1,200 units per hour 2 Keep legs elevated 3. Administer O2 at 2L/min 4. Elevate head of bed 30 degrees

2. Keep legs elevated

The nurse is assessing the lower extremities of the client with peripheral artery disease. Which findings are expected? SATA 1. Hairy legs 2. Mottled skin 3. Pink Skin 4. Coolness 5. Moist skin

2. Mottled skin 4. Coolness

A client with peripheral artery disease has undergone a right femoral-popliteal bypass graft. The BP has decreased from 124/80 mm Hg to 88/62 mmHg. What should the nurse assess FIRST? 1. IV fluid infusion rate 2. Pedal pulse 3. Nasal cannula flow rate 4. capillary refill

2. Pedal pulse

The health care provider prescribes a clonidine patch for a client with a BP that continues to be regularly above 160/100 mm Hg. Which statement is MOST important for the nurse to include in the teaching? 1. You can apply the patch to any area of your body that you can reach. 2. Rotate the sites you apply the patch to, avoiding scarred or irritated areas. 3. Avoid milk and other dairy foods, due to their high calcium content. 4. You can continue to drink alcohol, but you should not smoke cigarettes.

2. Rotate the sites you apply the patch to, avoiding scarred or irritated areas.

The nurse recognizes which medication is ineffective for the treatment of pulmonary emboli? 1. Tenectplase 2. Streptomycin 3. Reteplase 4. Alteplase (tPA)

2. Streptomycin- is an aminoglycoside used to treat various infections. Adverse effects include ototoxicity, anorexia, N/V/D.

A client has peripheral artery disease of both lower extremities. The client tells the nurse, " I've 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 minutes 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

2. The client walks slowly but steadily for 30 minutes twice a day.

A client is taking Verapamil in the sustained-release form that was prescribed one month ago. The client reports having a mild headache since starting the medication. Which information does the nurse provide to the client? 1. This is an unrelated symptom and should be reported. 2. This medication often causes headache which may improve with time. 3. This medication should be stopped until the headache disappears. 4. The client should go immediately to the emergency department.

2. This medication often causes headaches which may improve with time.

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

A client diagnosed with congestive heart failure is prescribed hydrocholorthiazide 50 mg PO once a day. What is the BEST time for the nurse to administer this medication? 1. One hour before breakfast 2. with breakfast 3. with dinner 4. At bedtime

2. with breakfast.

Which is the correct action for the nurse to take when monitoring an adult clients BP? 1. Loosely position the cuff loosely 2-3 inches above the site of the brachial pulse 2. Position the clients arm below the level of the heart 3. Rapidly inflate the cuff to 200 mm Hg 4. Record the first and the last audible Korotkoff sounds as the BP reading

4. Record the first and the last audible Korotkoff sounds as the BP

The nurse prepares to check the BP of a client who weighs 250 pounds. Which is the MOST likely outcome if the nurse uses a regular adult-sized BP cuff? 1. The BP cuff reading will be accurate 2. The BP reading will be accurate if an ultrasound stethoscope is used 3. The BP will be lower that the actual reading 4. The BP will be higher than the actual reading

4. The BP will be higher than the actual reading. - The BP will be inaccurate and elevated if the cuff is too narrow. The cuff should be approximately 40% of the clients arm circumference

The nurse is planning discharge teaching for a client diagnosed with peripheral vascular disease. The nurse reviews the clients health history. It is MOST important for the nurse to address which issue? 1. The client drinks socially 2. The client walks daily 3. The client takes vitamins daily 4. The client smokes daily.

4. The client smokes daily

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 in the calf during exercise that disappears at rest. Which finding requires further evaluation? 1. HR 57 bpm 2. SpO2 of 94% on room air 3. BP 134/82 mm Hg 4. ankle-brachial index of 0.65

4. ankle-brachial index of 0.65

When the nurse is assessing an individual with peripheral artery disease, which clinical manifestation would indicate 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

The nurse understands which reason is the cause of primary hypertension? 1. A high-sodium diet 2. Kidney diease 3. obesity 4. unknown

4. unknown

A client is receiving Cilostazol for peripheral artery disease causing intermittent claudication. Which statement by the client indicates to the nurse that this medication is effective.? 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 color."

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

The nurse instructs a client diagnosed with atrial fibrillation receiving lisinopril. Which statement, if made by the client to the nurse, indicates the need for further teaching? 1. "I have to limit the amount of canned soup, lunch meats, and cheese i eat." 2. "I will decrease the number of oranges, bananas, and apricots in my diet." 3. "I have switched to a salt substitute instead of iodized salt." 4. "I do not include as much broccoli, potatoes, and leafy green vegetables in my diet."

3. "I have switched to a salt substitute instead of iodized salt." - they should avoid both high-sodium and high-potassium foods; should use seasonings other than salt or salt substitute.

The nurse is caring for a client with peripheral artery disease who has recently been prescribed Clopidogrel. Which statement by the client indicates that the nurse should continue giving information to the client about this medicine? 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 dizzy and weak." 4. " The doctor prescribed this medicine to make my platelets less likely to stick together and help prevent clots from forming."

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

When providing care for a postoperative client, the nurse identifies which as the BEST intervention to prevent thromboembolism? 1. Maintain bed rest for the first 24 hours postoperatively 2. Administer oxygen therapy via nasal cannula 3. Apply sequential compression devices to the legs. 4. Assess the calf for pain and tenderness

3. Apply sequential compression devices to the legs

A two day postoperative client reports pain, tenderness, and redness of the right calf. Which findings would be CRITICAL for the nurse to report to the health care provider regarding the clients s/s? 1. Nausea and abdominal distention 2. Back pain and hematuria 3. Chest pain and shortness of breath 4. Mild redness around the surgical incision

3. Chest pain and shortness of breath

A client with heart failure has bilateral +4 edema of the right ankle that extends up to midcalf. The client is sitting in a chair in no evident distress with the legs in a dependent position. What should the nurse do first? 1. Assist the client to the bed 2. Request a prescription for support stockings 3. Elevate the clients legs on a foot stool 4. Take the clients BP

3. Elevate the clients legs on a foot stool

The nurse plans to care for a client diagnosed with ulcerations and infections of the feet related to peripheral vascular disease. Which intervention does the nurse include in the plan of care for this client? 1. Use a heating pad for foot discomfort 2. Soak the clients feet daily 3. Elevate the feet if swollen 4. Use lotion between the clients toes.

3. Elevate the feet if swollen

The nurse provides care for a client receiving Methyldopa. The nurse instructs the client about common adverse affects of Methyldopa. Which information does the nurse include? 1. Bronchospasms 2. Loss of potassium 3. Loss of Libido 4. Tachycardia

3. Loss of Lipido- Methyldopa is a centrally acting sympatholytic that reduces peripheral vascular resistance. Adverse effects include drowsiness, sedation, orthostatic hypotension, bradycardia, wt gain, nightmares, and loss of libido. Methyldopa should not be discontinued abruptly, as this may cause hypertensive crisis.

The nurse understands that intermittent claudication is which description? 1. Found in venous insufficiency 2. Pain caused by cold 3. Pain caused by walking 4. Found only in the elderly

3. Pain caused by walking.

A client is admitted for a revascularization procedure for arteriosclerosis in the left iliac artery. What should the nurse do to promote circulation in the extremities? 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.

3. Position the left leg at or below the body's horizontal plane

Which indicates the CORRECT rationale for the nurse placing antiembolism stockings on a client diagnosed with spinal cord injury? 1. Facilitate and regain sensation in the legs 2. Prevent edema to the lower extremities 3. Prevent venous stasis and thrombophlebitis 4. Prevent varicose veins from developing in the legs

3. Prevent venous stasis and thrombophlebitis

A client diagnosed with iron deficiency anemia receives heparin after a venous thromboembolism (VTE) is diagnosed in the left leg. Which observation MOST concerns the nurse? 1. The client passes a black stool 2. The client is pale. 3. The client has a nosebleed. 4. The client is confused.

3. The client has a nosebleed. - active bleeding from any body site can indicate hemorrhage, the primary concern with anticoagulant medications.

Which statement MOST accurately describes BP assessment in an adult clients lower extremities? 1. The BP reading will be the same as the reading obtained in the arm. 2. The cuff will be placed around the thigh and the stethoscope at the dorsalis pedis pulse 3. The client will be positioned on the abdomen 4. The systolic reading may be the same as the BP obtained at the brachial artery but the diastolic will be 10 to 40 mmHg higher

3. The client will be positioned on the abdomen- this is the best position to obtain an accurate BP reading in the adult clients lower extremity. The nurse places the BP cuff around the thigh and the stethoscope at the popliteal artery.

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 medications 2. ensure fluid intake of 3000 mL per 24 hours 3. Turn the client every 1-2 hours 4. maintain hygiene

3. Turn the client every 1-2 hours

The nurse is unable to palpate the clients left pedal pulse. What should the nurse do FIRST? 1. auscultate the pulses with a stethoscope 2. call the health care provider 3. use a doppler ultrasound device 4. Inspect the lower left extremity

3. Use a doppler ultrasound device

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 nurse determines that the black color is caused by which factor? 1. atrophy 2. contraction 3. gangrene 4. rubor

3. gangrene

The nurse assesses a postoperative client for orthostatic hypotension before ambulating the client for the first time. Which action is MOST important for the nurse to take? 1. Measure the clients BP in at least 3 different positions. 2. Allow one minute between the clients change in positions. 3. Observe the client for a drop in BP and/or an increase in pulse 4. Determine if the client is taking an oral beta blocker medication.

3. observe the client for a drop in BP and/or an increase in pulse

One goal in caring for a client with arterial occulsive disease is to promote vasodialtion in the affected extremity. What should the nurse instruct the client to do to achieve this goal? 1. Avoid eating low-fat foods 2. Elevate the legs above the heart 3. Stop smoking 4. Jog daily

3. stop smoking

The nurse is assessing the pulse in a client with aortoiliac disease. Which pulse site will the nurse get the most useful data?

Femoral

A client who has been diagnosed with peripheral artery disease is being discharged. What statement by the client indicates the client need further instruction? 1. " I don't use a heating pad." 2. " I'll sit in a chair with both of my legs on the floor." 3. " I wear leather shoes when I'm out of bed 4. " I should wipe any injury with iodine on a cotton ball."

4. " I should wipe any injury with iodine on a cotton ball."

A client is scheduled to undergo right axillary-to-axillary artery bypass surgery. Immediately following the surgery, what should the nurse do as a priority to prevent infection? 1. Asses 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 a venipuncture

4. Avoid using the arm for a venipuncture

The nurse is obtaining the pulse of a client who has had a femoral-popliteal bypass surgery 6 hours ago. Which assessment provides the most accurate information about the clients postoperative status. 1. Radial pulse 2. Femoral Pulse 3. Apical Pulse 4. Dorsalis pedis pulse

4. Dorsalis-pedis pulse

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 provides care for a client diagnosed with hypertension. The client tells the nurse, "I no longer take my medication." Which is MOST appropriate nursing action? 1. Call the health care provider 2. Tell the client there is no choice but to take the medication 3. Inform the client to check BP daily. If it goes up, the client should start taking the medications again. 4. Explore reasons for stopping the medication with the client

4. Explore reasons for stopping the medications with the client

The nurse provides instruction to a client about hypertension. Which client statement best indicates teaching is successful? 1. I will be able to tell when my BP is elevated 2. Hypertension is caused by eating too much salt 3. I can stop taking the medication when my BP reading goes down 4. I will make appointments to see my health care provider on a regular basis

4. I will make appointments to see my health care provider on a regular basis.

The nurse provides care for a client diagnosed with peripheral arterial disease. The client reports being awakened with severe pain in the legs. Which pathological condition does the nurse explain to the client? 1. Arteriosclerosis 2. Lymphedema 3. Edema of the lower extremities 4. Inadequate tissue oxygenation

4. Inadequate tissue oxygenation