Nursing V: Unit 5
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. Any neurovascular abnormality in the client's lower extremities indicates the graft is occluded or possibly bleeding and requires immediate intervention by the nurse.
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. The decreased oxygen over time causes the loss of hair on the tops of the feet and ascending both legs.
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. Assessment is the first part of the nursing process and is the first intervention the nurse should implement.
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. An absent pulse is not uncommon in a client diagnosed with arterial occlusive disease, but the nurse must ensure that the feet can be moved and are warm, which indicates adequate blood supply to the feet.
The client diagnosed with an ST elevation myocardial infarction (STEMI) has developed 2+ edema bilaterally of the lower extremities and has crackles in all lung fields. Which should the nurse implement first? 1. Notify the health care provider (HCP). 2. Assess what the client ate at the last meal. 3. Request a STAT 12 lead electrocardiogram. 4. Administer furosemide IVP.
1. "Has developed" indicates a new issue; the nurse should notify the HCP of the assessment findings, which indicate that the client has developed heart failure.
Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? Select all that apply. 1. Encourage a low-fat, low-cholesterol diet. 2. Instruct the client to walk 30 minutes a day. 3. Decrease the salt intake to two (2) g a day. 4. Refer to a counselor for stress reduction techniques. 5. Teach the client to increase fiber in the diet.
1. A low-fat, low-cholesterol diet will help decrease the buildup of atherosclerosis in the arteries. 2. Walking will help increase collateral circulation. 4. Stress reduction is encouraged for clients with CAD because this helps prevent excess stress on the heart muscle. 5. Increasing fiber in the diet will help remove cholesterol via the gastrointestinal system.
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. A modifiable risk factor is a risk factor that can possibly be altered by modifying or changing behavior, such as developing new ways to deal with stress.
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 HDLs? 1. A normal HDL is good because it has a protective action in the body. 2. The HDL 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. A normal HDL level is good because HDL transports cholesterol away from the tissues and cells of the arterial wall to the liver for excretion. This helps decrease the development of atherosclerosis.
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.
1. Adherence to lifestyle modifications is enhanced when the client receives support from significant others. 2. Tobacco use is the most significant modifiable risk factor that contributes to the development of atherosclerosis.
The intensive care department nurse is assessing the client who is 12 hours post-myocardial infarction. The nurse assesses an S3 heart sound. Which intervention should the nurse implement? 1. Notify the health-care provider immediately. 2. Elevate the head of the client's bed. 3. Document this as a normal and expected finding. 4. Administer morphine intravenously.
1. An S3 indicates left ventricular failure and should be reported to the health-care provider. It is a potential life-threatening complication of a myocardial infarction.
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. The client has a foot ulcer; therefore, the protective lining of the body—the skin—has been impaired.
The nurse is demonstrating the use of a blood pressure sphygmomanometer to a client newly diagnosed with hypertension. Which should the nurse teach the client? Select all that apply. 1. Tell the client to make sure the cuff is placed over an artery. 2. Teach the client to notify the health-care provider if the BP is > 160/100. 3. Instruct the client about orthostatic hypotension. 4. Encourage the client to keep a record of the blood pressure readings. 5. Explain that even when the blood pressure is within normal limits the medication should still be taken.
1. Blood pressure readings measure arterial pressures; the cuff should be placed so the pressure in an artery can be read. 2. The client should be instructed as to when to notify the HCP. BP readings over 160 systolic or 100 diastolic indicate the blood pressure is not controlled and the medication regimen might need to be adjusted. 3. Antihypertensive medications can cause a drop in the blood pressure when the client changes from a sitting or lying position to an upright position because of gravity and relaxed blood vessels. This is orthostatic hypotension; the blood vessels will adjust if the client rises slowly or sits on the side of the bed for a short time. 4. A record of the blood pressure reading obtained by the client can assist the HCP in planning the suggested regimen. 5. Many clients decide that if they are WNL the medication is no longer needed. The client should understand if the readings are WNL it is because of the medication and stopping the medication will stop the desired effect.
Which arterial anticoagulant medication would the nurse anticipate being prescribed for a client diagnosed with arterial occlusive disease? 1. Clopidogrel. 2. Streptokinase. 3. Protamine sulfate. 4. Enoxaparin.
1. Clopidogrel (Plavix) is an arterial antiplatelet that prevents clots from occurring in the lower extremity arteries.
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. Cold water causes vasoconstriction and hot water may burn the client's feet; therefore, warm (tepid) water should be recommended. 2. Moisturizing prevents drying of the feet. 4. This will further decrease circulation to the legs. 5. Colored socks have dye, and dirty socks may cause foot irritation that may lead to breaks in the skin.
The nurse is discussing the importance of exercising with a client who is diagnosed with coronary artery disease. 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. Collateral circulation is the development of blood supply around narrowed arteries; it helps prevent complications of atherosclerosis, including myocardial infarction, cerebrovascular accidents, and peripheral vascular disease. Exercise promotes the development of collateral circulation.
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. Even if the client feels great, the blood pressure can be elevated, causing damage to the heart, kidney, and blood vessels.
The client is admitted for surgical repair of an 8-cm abdominal aortic aneurysm (AAA). 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. Low back pain is present because of the pressure of the aneurysm on the lumbar nerves; this is a serious symptom, usually indicating that the aneurysm is expanding rapidly and about to rupture.
The nurse is caring for a client diagnosed with coronary artery disease (CAD). Which should the nurse teach the client prior to discharge? 1. Carry your nitroglycerin tablets in a brown bottle. 2. Swallow a nitroglycerin tablet at the first sign of angina. 3. If one nitroglycerin tablet does not work in 10 minutes, take another. 4. Nitroglycerin tablets have a fruity odor if they are potent.
1. Nitroglycerin tablets are dispensed in small brown bottles to preserve the potency. The client should not change the tablets to another container.
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 the HCP of any redness or irritation of the incision. 2. Do not lift anything that weighs more than 20 pounds. 3. Inform the client there may be pain not relieved with pain medication. 4. Stress the importance of having daily bowel movements.
1. Redness or irritation of the incision indicates infection and should be reported immediately to the HCP.
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. The DASH diet has proved beneficial in lowering blood pressure. It recommends eating a diet high in vegetables and fruits.
The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement? 1. Instruct the client to keep a diary of activity, especially when having chest pain. 2. Discuss the need to remove the Holter monitor during a.m. care and showering. 3. Explain that all medications should be withheld while wearing a Holter monitor. 4. Teach the client the importance of decreasing activity while wearing the monitor.
1. The Holter monitor is a 24-hour electrocardiogram, and the client must keep an accurate record of activity so that the health-care provider can compare the ECG recordings with different levels of activity.
The client diagnosed with a myocardial infarction asks the nurse, "Why do I have to rest and take it easy? My chest doesn't hurt anymore." Which statement would be the nurse's best response? 1. "Your heart is damaged and needs about four (4) to six (6) weeks to heal." 2. "There is necrotic myocardial tissue that puts you at risk for dysrhythmias." 3. "Your doctor has ordered bedrest. Therefore, you must stay in the bed." 4. "Just because your chest doesn't hurt anymore doesn't mean you are out of danger."
1. The heart tissue is dead, stress or activity may cause heart failure, and it does take about six (6) weeks for scar tissue to form.
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.
1. The most common cause of AAA is atherosclerosis, so teaching should address this area. 2. A low-fat, low-cholesterol diet will help decrease development of atherosclerosis. 4. Losing weight will help decrease the pressure on the AAA and will help address decreasing the cholesterol level.
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 hemorrhagic 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.
1. The nurse should check the laboratory values pertaining to the medications before administering the medications.
The client with coronary artery disease asks the nurse, "Why do I get chest pain?" Which statement would be the most appropriate response by the nurse? 1. "Chest pain is caused by decreased oxygen to the heart muscle." 2. "There is ischemia to the myocardium as a result of hypoxemia." 3. "The heart muscle is unable to pump effectively to perfuse the body." 4. "Chest pain occurs when the lungs cannot adequately oxygenate the blood."
1. This is a correct statement presented in layman's terms. When the coronary arteries cannot supply adequate oxygen to the heart muscle, there is chest pain.
The nurse is teaching the client recently diagnosed with essential hypertension. Which instruction should the nurse provide when discussing heart healthy 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-intensity aerobics daily. 4. Encourage the client to swim laps once a week.
1. Walking 30 to 45 minutes a day will help to reduce blood pressure, weight, and stress and will increase a feeling of overall well-being.
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. When the aneurysm is small (less than 5 to 6 cm), an abdominal sonogram will be done every six (6) months until the aneurysm reaches a size at which surgery to prevent rupture is of more benefit than possible complications of an abdominal aortic aneurysm repair.
The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to question administering the medication? 1. The client has a BP of 110/70. 2. The client has an apical pulse of 56. 3. The client is complaining of a headache. 4. The client's potassium level is 4.5 mEq/L.
2. A beta blocker decreases sympathetic stimulation to the heart, thereby decreasing the heart rate. An apical rate less than 60 indicates a lower-than-normal heart rate and should make the nurse question administering this medication because it will further decrease the heart rate.
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. A systolic bruit over the abdomen is a diagnostic indication of an AAA.
Which complication of anticoagulant therapy should the nurse teach the client to report to the health-care provider? 1. Gastric upset. 2. Bleeding from any site. 3. Constipation. 4. Myocardial infarction.
2. Anticoagulant therapy reduces the client's ability to form clots; bleeding is the most important issue to discuss with the client.
The nurse is caring for a client diagnosed with a myocardial infarction who is experiencing chest pain. Which interventions should the nurse implement? Select all that apply. 1. Administer morphine intramuscularly. 2. Administer an aspirin orally. 3. Apply oxygen via a nasal cannula. 4. Place the client in a supine position. 5. Administer nitroglycerin subcutaneously.
2. Aspirin is an antiplatelet medication and should be administered orally. 3. Oxygen will help decrease myocardial ischemia, thereby decreasing pain.
Along with persistent, crushing chest pain, which signs/symptoms would make the nurse suspect that the client is experiencing a myocardial infarction? 1. Midepigastric pain and pyrosis. 2. Diaphoresis and cool, clammy skin. 3. Intermittent claudication and pallor. 4. Jugular vein distention and dependent edema.
2. Diaphoresis (sweating) is a systemic reaction to the MI. The body vasoconstricts to shunt blood from the periphery to the trunk of the body; this, in turn, leads to cold, clammy skin.
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 nothing by mouth (NPO) after midnight.
2. Increased pressure in the abdomen secondary to a tap water enema could cause the AAA to rupture.
Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease? 1. Assess the client's radial pulse. 2. Assess the client's serum potassium level. 3. Assess the client's glucometer reading. 4. Assess the client's pulse oximeter reading.
2. Loop diuretics cause potassium to be lost in the urine output. Therefore, the nurse should assess the client's potassium level, and if the client is hypokalemic, the nurse should question administering this medication.
The nurse is teaching a class to clients diagnosed with hypertension. Which should the nurse teach the clients? 1. The blood pressure target range should be 120/80. 2. Take the medication even when feeling well. 3. Get up quickly when rising from a recumbent position. 4. Consume a 3,000-mg sodium diet.
2. Many clients decide that because they do not feel ill, medication is not needed. Hypertension is called the silent killer because damage to the body can occur without the client realizing it.
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 lie down after eating."
2. Only about two-fifths of clients with AAA have symptoms; the remainder are asymptomatic.
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. Rapid weight gain—for example, 2 kg in one (1) to two (2) days—indicates that the loop diuretic is not working effectively; 2 kg equals 4.4 lb; 1 L of fluid weighs l kg.
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. Rest pain indicates a worsening of the arterial occlusive disease; the muscles of the legs are not getting enough oxygen when the client is resting to prevent muscle ischemia.
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. Sedentary lifestyle is discouraged in clients with hypertension; daily isotonic exercises are recommended. Smoking (cigars have problems too) increases the atherosclerotic process in vessels; causes vasoconstriction of vessels; and adheres to hemoglobin, decreasing oxygen levels.
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. Statin medications should be taken in the evening for best results because the enzyme that destroys cholesterol works best in the evening and the medication enhances this process.
The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take first when experiencing angina? 1. Put a nitroglycerin tablet under the tongue. 2. Stop the activity immediately and rest. 3. Document when and what activity caused angina. 4. Notify the health-care provider immediately.
2. Stopping the activity decreases the heart's need for oxygen and may help decrease the angina (chest pain).
Which statement by the client diagnosed with coronary artery disease indicates that the client understands the discharge teaching concerning diet? 1. "I will not eat more than six (6) eggs a week." 2. "I should bake or grill any meats I eat." 3. "I will drink eight (8) ounces of whole milk a day." 4. "I should not eat any type of pork products."
2. The American Heart Association recommends a low-fat, low-cholesterol diet for a client with coronary artery disease. The client should avoid any fried foods, especially meats, and bake, broil, or grill any meat.
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. The UAP can feed a client.
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 DVT 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 non-bloody diarrhea.
2. The chest pain could be a pulmonary embolus secondary to deep vein thrombosis and requires immediate intervention by the nurse.
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. The client must have 30 mL of urinary output every hour. Clients who are post-AAA are at high risk for renal failure because of the anatomical location of the AAA near the renal arteries.
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. The client needs to be taught ways to lower the cholesterol level.
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. The diastolic blood pressure should be less than 85 mm Hg according to the American Heart Association; therefore, this client should see the health-care provider.
The client is one (1) day postoperative coronary artery bypass surgery. The client complains of chest pain. Which intervention should the nurse implement first? 1. Medicate the client with intravenous morphine. 2. Assess the client's chest dressing and vital signs. 3. Encourage the client to turn from side to side. 4. Check the client's telemetry monitor.
2. The nurse must always assess the client to determine if the chest pain that is occurring is expected postoperatively or if it is a complication of the surgery.
The client is scheduled for a right femoral cardiac catheterization. Which nursing intervention should the nurse implement after the procedure? 1. Perform passive range-of-motion exercises. 2. Assess the client's neurovascular status. 3. Keep the client in high Fowler's position. 4. Assess the gag reflex prior to feeding the client.
2. The nurse must make sure that blood is circulating to the right leg, so the client should be assessed for pulses, paresthesia, paralysis, coldness, and pallor.
The client diagnosed with a myocardial infarction (MI) is being discharged. Which discharge instruction(s) should the nurse teach the client? 1. Call the health care provider (HCP) if any chest pain happens. 2. Discuss when the client can resume sexual activity. 3. Explain the pharmacology of nitroglycerin tablets. 4. Encourage the client to sleep with the head of the bed elevated.
2. The nurse should make sure the client is aware of when sexual activity can be safely resumed.
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 less than 90/60 mm Hg. 3. Do not administer the medication if the client's radial pulse is greater than 100. 4. Monitor the client's BP while he or she is lying, standing, and sitting.
2. The nurse should question administering the beta blocker if the BP is low because this medication will cause the blood pressure to drop even lower, leading to hypotension.
The 45-year-old male client diagnosed with essential hypertension has decided not to take his medications. The client's BP is 178/94, indicating a perfusion issue. Which question should the nurse ask the client first? 1. "Do you have the money to buy your medication?" 2. "Does the medication give unwanted side effects?" 3. "Did you quit taking the medications because you don't feel bad?" 4. "Can you tell me why you stopped taking the medication?"
2. This is a mild way of introducing the subject of side effects to a client not wishing to admit the medication causes unwanted effects. It opens the door to more probing assessment questions. The nurse should bring up the subject in order to allow the client to be forthcoming with the issues of why he is not taking his medication.
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. This is the classic symptom of arterial occlusive disease.
The charge nurse is making assignments for clients on a cardiac unit. Which client should the charge nurse assign to a new graduate nurse? 1. The 44-year-old client diagnosed with a myocardial infarction. 2. The 65-year-old client admitted with unstable angina. 3. The 75-year-old client scheduled for a cardiac catheterization. 4. The 50-year-old client complaining of chest pain.
3. A new graduate should be able to complete a preprocedure checklist and get this client to the catheterization laboratory.
The health-care provider prescribes an angiotensin-converting enzyme (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. Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of angiotensin I to angiotensin II and this, in turn, prevents vasoconstriction and sodium and water retention.
The nurse is caring for a male client diagnosed with essential hypertension. Which information regarding antihypertensive medication should the nurse teach? 1. Teach the client to take his blood pressure four (4) times each day. 2. Instruct the client to have regular blood levels of the medication checked. 3. Explain the need to rise slowly from a lying or sitting position. 4. Demonstrate how to use a blood glucose meter daily.
3. Antihypertensive medications can cause a drop in the blood pressure when the client changes positions from a sitting or lying position to an upright position because of gravity and relaxed blood vessels. This is orthostatic hypotension; the blood vessels will adjust if the client rises slowly or sits on the side of the bed for a short time.
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. Antiplatelet medications, such as aspirin or clopidogrel (Plavix), inhibit platelet aggregations in the arterial blood.
The client diagnosed with a myocardial infarction is six (6) hours post-right femoral percutaneous transluminal coronary angioplasty (PTCA), also known as balloon surgery. Which assessment data would require immediate intervention by the nurse? 1. The client is keeping the affected extremity straight. 2. The pressure dressing to the right femoral area is intact. 3. The client is complaining of numbness in the right foot. 4. The client's right pedal pulse is 3+ and bounding.
3. Any neurovascular assessment data that are abnormal require intervention by the nurse; numbness may indicate decreased blood supply to the right foot.
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. Baked, broiled, or grilled meats are recommended; a plain baked potato is appropriate; and skim milk is low in fat—so this meal is appropriate for a low-fat, low-cholesterol diet.
The client who has had a myocardial infarction is admitted to the telemetry unit from intensive care. Which referral would be most appropriate for the client? 1. Social worker. 2. Physical therapy. 3. Cardiac rehabilitation. 4. Occupational therapy.
3. Cardiac rehabilitation is the most appropriate referral. The client can start rehabilitation in the hospital and then attend an outpatient cardiac rehabilitation clinic, which includes progressive exercise, diet teaching, and classes on modifying risk factors.
The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse? 1. The client's BP is 110/70 and pulse is 90. 2. The client's groin dressing is dry and intact. 3. The client refuses to keep the leg straight. 4. The client denies any numbness and tingling.
3. If the client bends the leg, it could cause the insertion site to bleed. This is arterial blood and the client could bleed to death very quickly, so this requires immediate intervention.
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. Intermittent claudication is a sign of generalized atherosclerosis and is a marker of atherosclerosis.
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. Numbness and tingling are paresthesia, which is a sign of a severely decreased blood supply to the lower extremities.
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. PT/INR is a test to monitor warfarin (Coumadin) action in the body.
The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching? 1. "Do you have a daily bowel movement?" 2. "Do you get yearly chest x-rays (CXRs)?" 3. "Are you sexually active?" 4. "Have you had any weight change?"
3. Sexual activity is a risk factor for angina resulting from coronary artery disease. The client's being elderly should not affect the nurse's assessment of the client's concerns about sexual activity.
The client diagnosed with rule-out myocardial infarction is experiencing chest pain while walking to the bathroom. Which action should the nurse implement first? 1. Administer sublingual nitroglycerin. 2. Obtain a STAT electrocardiogram (ECG). 3. Have the client sit down immediately. 4. Assess the client's vital signs.
3. Stopping all activity will decrease the need of the myocardium for oxygen and may help decrease the chest pain.
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. The most common cause of AAA is atherosclerosis (which is the cause of peripheral vascular disease); it occurs in men four (4) times more often than in women and primarily in Caucasians.
The client diagnosed with a myocardial infarction is on bedrest. The unlicensed assistive personnel (UAP) is encouraging the client to move the legs. Which action should the nurse implement? 1. Instruct the UAP to stop encouraging the leg movements. 2. Report this behavior to the charge nurse as soon as possible. 3. Praise the UAP for encouraging the client to move the legs. 4. Take no action concerning the UAP's behavior.
3. The nurse should praise and encourage UAPs to participate in the client's care. Clients on bedrest are at risk for deep vein thrombosis, and moving the legs will help prevent this from occurring.
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.
4. Fluids will help flush the contrast dye out of the body and help prevent kidney damage.
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. There is no known cause for essential hypertension, but many factors—both modifiable (obesity, smoking, diet) and nonmodifiable (family history, age, gender)—are risk factors for essential hypertension.
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. This is the scientific rationale for why diabetes mellitus is a modifiable risk factor for atherosclerosis.
Which cardiac enzyme would the nurse expect to elevate first in a client diagnosed with a myocardial infarction (MI)? 1. Creatine kinase (CK-MB). 2. Lactate dehydrogenase (LDH). 3. Troponin. 4. White blood cells (WBCs).
3. Troponin is the enzyme that elevates within 1 to 2 hours.
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. Walking promotes the development of collateral circulation to ischemic tissue and slows the process of atherosclerosis.
The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement? 1. Perform isometric exercises daily. 2. Walk for 15 minutes three (3) times a week. 3. Do not walk outside if it is less than 40°F. 4. Wear open-toed shoes when ambulating.
3. When it is cold outside, vasoconstriction occurs, and this will decrease oxygen to the heart muscle. Therefore, the client should not exercise when it is cold outside.
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.
4. After the surgery, the client's legs will be elevated to help decrease edema. The surgery has corrected the decreased blood supply to the lower legs.
The client is at risk for a myocardial infarction due to decreased tissue perfusion as a result of atherosclerosis. Which instructions can the nurse provide the client to reduce the risk? 1. Teach the client to control the blood pressure to less than 140/90. 2. Instruct the client to exercise 30 minutes a day three (3) times a week. 3. Demonstrate how to take the blood pressure using a battery-operated cuff. 4. Inform the client to limit fat intake and which foods have a higher fat content.
4. Atherosclerosis is caused by plaque buildup in the arteries. Plaque is primarily caused by fat in the diet compounded by clotting mechanisms.
The male client diagnosed with essential hypertension has been prescribed an alpha-adrenergic 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 a lying to sitting position.
4. Orthostatic hypotension may occur when the blood pressure is decreasing and may lead to dizziness and light-headedness, so the client should change position slowly.
The nurse is admitting a client diagnosed with coronary artery disease (CAD) and angina. Which concept is priority? 1. Sleep, rest, activity. 2. Comfort. 3. Oxygenation. 4. Perfusion.
4. The cardiac muscle is not perfused when there is a narrowing of the arteries caused by CAD or when an embolus or a thrombus occludes the artery. Adequate perfusion will supply oxygen to the cardiac muscle, allow for increased activity, and decrease pain.
The nurse is caring for a client who suddenly complains of crushing substernal chest pain while ambulating in the hall. Which nursing action should the nurse implement first? 1. Call a Code Blue. 2. Assess the telemetry reading. 3. Take the client's apical pulse. 4. Have the client sit down.
4. The client began to have a problem during physical exertion. Stopping the exertion should be the first action taken by the nurse.
The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching? 1. "I should keep the tablets in the dark-colored bottle they came in." 2. "If the tablets do not burn under my tongue, they are not effective." 3. "I should keep the bottle with me in my pocket at all times." 4. "If my chest pain is not gone with one tablet, I will go to the ER."
4. The client should take one tablet every five (5) minutes and, if no relief occurs after the third tablet, have someone drive him to the emergency department or call 911.
The nurse is planning care for a client diagnosed with arterial occlusive disease. Which exercise instructions would the nurse teach the client? 1. Have the client perform isometric exercises 30 minutes each day. 2. Tell the client to start exercising on a stair stepper for 15 minutes. 3. Inform the client that warm-up exercises are not necessary. 4. Teach the client to walk in well-fitting shoes on level ground.
4. The client should walk as the preferred form of exercise, the shoes should fit the client without causing blisters, and walking on level ground decreases the risk of injury or excessive stress on the muscles.
The nurse is administering a calcium channel blocker to the client diagnosed with a myocardial infarction. Which assessment data would cause the nurse to question administering this medication? 1. The client's apical pulse is 64. 2. The client's calcium level is elevated. 3. The client's telemetry shows occasional PVCs. 4. The client's blood pressure is 90/58.
4. The client's blood pressure is low, and a calcium channel blocker could cause the blood pressure to bottom out.
The nurse enters the client's room and notes an unconscious client with an absence of respirations and no pulse or blood pressure. The concept of perfusion is identified by the nurse. Which should the nurse implement first? 1. Notify the health care provider. 2. Call a rapid response team (RRT). 3. Determine the telemetry monitor reading. 4. Push the Code Blue button.
4. The first action is to immediately notify the code team and initiate CPR per protocol.
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.
4. The leg dressing needs to be assessed for hemorrhaging or signs of infection.
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."
4. This response explains in plain terms why the client's legs hurt from atherosclerosis.
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.
4. Tobacco use is the strongest factor in the development of atherosclerotic lesions. Nicotine decreases blood flow to the extremities and increases heart rate and blood pressure. It also increases the risk of clot formation by increasing the aggregation of platelets.
