Adult Health II, Exam 3

24. The nurse and an unlicensed nursing assistant are caring for a 64-year-old client who is four (4) hours post-operative bilateral femoral-popliteal bypass surgery. Which nursing task should be delegated to the unlicensed nursing assistant? 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. Elevate the foot of the client's bed. After surgery, the client's legs will be elevated to help decreased edema. The surgery has corrected the decreased blood flow supply to the lower extremities. Continuous passive motion machine (CPM) is used for knee surgeries. Client will be on bed rest for at least 4 hours.

18. The client diagnosed with arterial occlusive disease is one (1) day post operative right femoral-popliteal bypass. Which intervention should the nurse implement? a. keep the right leg in the dependent position b. apply sequential compression devices to lower extremities c. monitor the client's pedal pulses every shift d. assess the client's leg dressing every four (4) hours.

D. assess the client's leg dressing every four (4) hours. The leg dressing needs to be assessed for hemorrhaging or signs of infection. Monitoring should occur more than once per shift. SCD's will be applied only to the unaffected leg. The right leg should remain elevated to decrease edema.

The client is receiving prophylactic low molecular weight heparin. There are no PT/PTT or INR results on the client's chart since admission three (3) days ago. Which action should the nurse implement? a. Administer the medication as ordered. b. Notify the healthcare provider immediately. c. Obtain the PT/PTT and INR prior to administering the medication d. Hold the medication until the HCP makes rounds.

a. Administer the medication as ordered. Subcutaneous heparin will not achieve a therapeutic level because of the short half life of the medication; therefore the nurse should administer the medication. There is no need to notify the healthcare provider or monitor lab results.

Which nursing intervention is essential for the patient receiving alteplase? a. Assess for reperfusion dysrhythmias. b.Monitor liver enzymes. c. Administer prescribed vitamin K if bruising is observed. d. Monitor blood pressure and stop the medication if blood pressure drops below 110 systolic.

a. Assess for reperfusion dysrhythmias. Alteplase can cause bleeding as well as reperfusion dysrhythmias. Alteplase does not directly affect liver enzymes. Vitamin K will not reverse the effects of alteplase. Vital sign changes can alert the nurse to complications; however, a blood pressure below 110 systolic is not, in itself, cause for alarm.

35. Which interventions should the nurse discuss with the client diagnosed with atherosclerosis? Select all that apply. a. Include significant other in the discussion. b. Stop smoking or using any type of tobacco products. c. Maintain a sedentary lifestyle as much as possible. d. Avoid stressful situations. e. Daily isometric exercises are important.

a. Include significant other in the discussion. b. Stop smoking or using any type of tobacco products. Adherence to a lifestyle modification is enhanced when the client receives support from significant others. Tobacco use is the most significant modifiable risk fact that contributes to the development of atherosclerosis.

80. The nurse is teaching the client diagnosed with deep vein thrombosis and prescribed warfarin. Which should the nurse teach the client? (Select all that apply) a. Keep a constant amount of green, leafy vegetables in the diet. b. instruct the client to have regular INR lab work done c. tell the client to go to the hospital immediately for any bleeding. d. inform the client to notify the HCP if having dark tarry stools e. encourage the client to avoid all green vegetables f. have the client take iron orally to prevent bleeding.

a. Keep a constant amount of green, leafy vegetables in the diet. b. instruct the client to have regular INR lab work done d. inform the client to notify the HCP if having dark tarry stools Changes in leafy green vegetables will change the anticoagulant effects on the body. The INR is the level that the HCP will use to gauge the anticoagulant effects and should be monitored regularly. Dark tarry stools indicate upper GI bleeding and the HCP should be informed.

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? a. Notify HCP of any redness or irritation of incision. b. Do not lift anything more than 20 pounds. c. Inform client that there may be pain not relieved with pain medication. d. Stress the importance of having daily bowel movements

a. Notify HCP of any redness or irritation of incision. Redness or irritation of the incision indicates infection and should be reported immediately to the HCP. Patients should not lift anything heavier than 5 pounds due to risk of dehiscence. Not all patients have daily bowel movements; but patients should be instructed to avoid constipation.

The nurse reviews the medical record of a client with hemorrhagic shock, which contains the following information: Pulse 140 beats/min and thready ABG: respiratory acidosis Blood pressure 60/40 mm Hg Lactate level 63 mg/dL(7 mmol/L) Respirations 40/min and shallow All of these provider prescriptions are given for the client. Which does the nurse carry out first? a. Notify anesthesia for endotracheal intubation. b. Give Plasmanate 1 unit now. c. Give normal saline solution 250 mL/hr. d. Type and crossmatch for 4 units of packed red blood cells (PRBCs).

a. Notify anesthesia for endotracheal intubation. The nurse must first notify anesthesia for endotracheal intubation for this client with hemorrhagic shock. Establishing an airway is the priority in all emergency situations.Although administering Plasmanate and normal saline, and typing and cross matching for 4 units of PRBCs are important actions, airway always takes priority.

When planning care for a client in the emergency department, which interventions are needed in the acute phase of myocardial infarction (MI)? (select all that apply) a. Oxygen b. Morphine Sulfate c. Nitroglycerine d. Nalaxone e. Acetaminophen

a. Oxygen b. Morphine Sulfate Administering oxygen will increase available oxygen for the ischemic myocardium during the acute phase of an MI. Morphine is also needed to reduce oxygen demand, preload, pain, and anxiety, and nitroglycerin is used to reduce preload and chest pain.Naloxone is a narcotic antagonist that is used for over dosage of opiates, not for MI. Acetaminophen may be used for headache related to nitroglycerin. Because of negative inotropic action, calcium channel blockers such as verapamil are used for angina, not for MI.

45. The client is diagnosed with a small abdominal aortic aneurysm. Which interventions should be included in the discharge teaching? Select all that apply. a. Tell the client to exercise three (3) times a week for 30 minutes. b. Encourage the client to eat a low-fat, low-cholesterol diet. c. Instruct the client to decrease tobacco use. d. Discuss with the client the importance of losing weight. e. Teach the client to wear a truss at all times.

a. Tell the client to exercise three (3) times a week for 30 minutes. b. Encourage the client to eat a low-fat, low-cholesterol diet. d. Discuss with the client the importance of losing weight. The most common cause of AAA is atherosclerosis, so teaching should address risk factors. Low fat, low cholesterol diet is important. Decreasing weight will decrease the amount of pressure on the AAA.

The UAP is applying elastic compression stockings to the client. Which action by the UAP would warrant immediate intervention by the nurse? a. The UAP is putting the stockings on while the client is in the chair. b. The UAP inserted two (2) fingers under the proximal end of the stocking. c. The UAP elevated the feet while lying down prior to putting on the stockings. d. The UAP made sure the toes were warm after putting the stockings on.

a. The UAP is putting the stockings on while the client is in the chair. Stocking should be applied after the legs have been elevated for a period of time; when the amount of blood in the legs would be at the lowest-- therefor the nurse would intervene when the UAP is trying to put stockings on while the client is in the chair.

38. Which medical treatment would be prescribed for the client with an AAA less than 3 cm? a. Ultrasound every six (6) months. b. Intravenous pyelogram yearly. c. Assessment of abdominal girth monthly. d. Repair of abdominal aortic aneurysm.

a. Ultrasound every six (6) months. When the aneurysm is small (less than 5-6cm), and abdominal sonogram will be done every six (6) months until the aneurysm reaches a size at which surgery will prevent rupture is of more benefit than possible complication of the repair procedure.

69. Which client would be most at risk for developing varicose veins? a. a Caucasian female who is a nurse b. An African American male who is a bus driver c. An Asian female with no children d. An elderly male with diabetes

a. a Caucasian female who is a nurse Varicose veins are more common in white females in occupations that involved prolonged standing. Increased risk during pregnancy. Diabetes may lead to diabetic neuropathy and arterial occlusive disease, but it does not lead to varicose veins.

85. Which arterial anticoagulant medication would the nurse anticipate being prescribed for a client diagnosed with arterial occlusive disease? a. clopidogrel b. streptokinase c. protamine sulfate d. enoxaparin

a. clopidogrel Clopidogrel (Plavix) is an arterial anti-platelet that prevents clots from occurring in the lower extremities. Enoxaparin is a subcutaneous low molecular weight heparin and not usually administered for arterial occlusive disease.

90. The nurse is caring for a client who is receiving heparin therapy intravenously. Which assessment data would indicate to the nurse the client is developing heparin induced thrombocytopenia (HIT)? Select all that apply. a. the client has spontaneous bleeding from around the IV site. b. the client complains of chest pain on inspiration and has become restless c. the client's platelet count on admission was 420 and now is 200 d. the client complains that the gums bleed when brushing teeth e. the client has developed skin lesions at the IV site.

b. the client complains of chest pain on inspiration and has become restless c. the client's platelet count on admission was 420 and now is 200 e. the client has developed skin lesions at the IV site. HIT is not manifested by bleeding but rather by the development of clots, either deep venous or pulmonary which can cause MI. HIT is a decrease in baseline platelet count by 50%. May manifest itself as skin lesions at the site of heparin injections of chills, fever, dyspnea, or chest pain.

59. The home health nurse is admitting a client diagnosed with a DVT. Which action by the client warrants immediate intervention by the nurse? a. The client takes a stool softener every day at dinnertime. b. The client is wearing a medic alert bracelet. c. The client takes vitamin E over-the-counter medications. d. The client has purchased a new recliner that will elevate the legs.

c. The client takes vitamin E over-the-counter medications. Vitamin E can affect the action of warfarin. The nurse should explain to the client that this can potentiate the effects of warfarin. Footrest recliner would be recommended but no the priority.

The nurse is caring for clients on a medical floor. Which client will the nurse assess first? a. The client with an abdominal aneurysm who is constipated. b. The client on bed rest who ambulated to the bathroom. c. The client with essential hypertension who has epistaxis and a headache. d. The client with arterial occlusive disease who has a decreased pedal pulse.

c. The client with essential hypertension who has epistaxis and a headache. A bloody nose and headache indicate the client is experiencing a very high blood pressure and should be assessed first because of a possible myocardial infarction/ stroke.

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? a. Arterial thrombosis. b. Deep vein thrombosis. c. Venous ulcerations. d. Varicose veins.

c. Venous ulcerations. Venous ulcerations are the most serious complication of chronic venous insufficiency. It is very difficult for these ulcers to heal and often client need referral to wound care clinics.

The visiting nurse is seeing a client postoperative for coronary artery bypass graft. Which nursing action would be performed first? a.Assess coping skills. b. Assess for postoperative pain at the client's incision site. c.Monitor the heart rate for dysrhythmias. d. Monitor mental status

c.Monitor the heart rate for dysrhythmias. The nurse would monitor the client's heart rate for dysrhythmias. Dysrhythmias are the leading cause of prehospital death.Assessing mental status, coping skills, or postoperative pain is not the priority for this client.

75 The client diagnosed with a deep vein thrombosis is prescribed heparin via continuous infusion. The client's lab data are: PT 12.2, Control 1.4, INR 1. Based on the laboratory results, which intervention should the nurse implement? a. request a change of medication to a subcutaneous anticoagulant b. administer aquamephyton (vit K) IM. c. Have the dietary department remove all green, leafy vegetables from the trays. d. Administer the IV as ordered

d. Administer the IV as ordered The client is in therapeutic range for IV heparin; the nurse should administered as ordered.

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. Complete a neurovascular assessment. 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.

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. "His legs are deprived of oxygen during periods of inactivity." Rest pain indicated 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.

87. 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). A. Tell the client to make sure the cuff is placed over an artery. B. Teach the client to notify the HCP if the BP is >160/100 C. Instruct the client about orthostatic hypotension D. Encourage the client to keep a record of the blood pressure readings E. Explain that even when the blood pressure is within normal limits the medication should be taken.

A, B, C, D, E. Anti hypertensive medications can cause orthostatic hypotension when the client changes position because of gravity and the relaxed blood vessels.

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) a. wash legs and feet daily in warm water b. apply moisturizing cream to feet. c. buy shoes in the morning hours only d. do not wear any type of knee stockings e. wear clean white cotton socks.

A, B, D, E. a. wash legs and feet daily in warm water b. apply moisturizing cream to feet. d. do not wear any type of knee stockings e. wear clean white cotton socks. Cold water cases vasoconstriction and hot water may burn the client's feet, warm water is recommended. Moisturizing prevents drying of the feet. Knee stocking will prevent arterial transport of blood to the lower extremities. Colored socks have dye, and dirty socks may lead to skin breakdown.

Which referral would be most appropriate for the client diagnosed with thoracic outlet syndrome? a. Physical therapist b. Thoracic surgeon c. Occupational therapist d. Social worker

A. Physical therapist Thoracic outlet syndrome is a compression of the subclavian artery at the thoracic outlet by an anatomical structure such as a rib or muscle. Physical therapy exercises, and avoiding aggravating positions are recommended treatments.

The client with left-sided mastectomy is diagnosed with elephantiasis of the left arm. Which signs/symptoms should the nurse expect to assess? a. edematous arm from the axillary area to the fingertips. b. painful, edematous, reddened lower forearm c. tented skin turgor over the entire left arm. d. Nipple retraction and peur d'orange skin.

A. edematous arm from the axillary area to the fingertips. Elephantitis is obstruction of the lymphatic vessels that causes chronic fibrosis, thickening of the subcutaneous tissue, and hypertrophy of the skin; this condition causes chronic edema of the extremity that recedes only slightly with elevation.

The nurse is teaching the client with peripheral vascular disease. Which interventions should the nurse discuss with the client. (Select all that apply) a. Wash your feet in antimicrobial soap b. Wear comfortable, well fitting shoes c. Cut your toenail in an arch d. Keep the area between the toes dry e. Use a heating pad when feet are cold.

B, D. Wear comfortable fitting shoes & keep the area between the toes dry. Comfortable shoes prevent blisters or ulcerations on the feet. Moisture between the toes increases fungal growth; leading to tissue breakdown. Antimicrobial soap is harsh and can dry the skin; the client should use mild soap at room temperature water. Toenails should be trimmed straight across; arch increases risk for ingrown toenails. Clients with PVD have decreased sensation in the feet and should not use a heating pad.

65. The nurse caring is for the client with chronic venous insufficiency. Which statement indicates the client understands the discharge teaching? a. "I shouldn't cross my legs for more than 15 minutes" b. "I need to elevate the foot of my bed while sleeping." c. "I should take a baby aspirin everyday with food." d. "I should increase my fluid intake to 3,000mL a day"

B. "I need to elevate the foot of my bed while sleeping." Elevating the foot of the bed while sleeping helps the venous blood return to the heart and decreases pressure in the lower extremities. Client should not cross legs at all bc this further impedes the blood from ascending the saphenous vein. Anti platelet therapy is for arterial disorders, not venous.

The client diagnosed with Buerger's disease (thromboangitis obliterans) asks the nurse, "What is the worst thing that could happen if I don't quit smoking? I love my cigarettes." Which statement is the nurses best response? a. "You are concerned about quitting smoking. Let's sit down and talk about it. b. "Many clients end up having to have an amputation, especially a leg." c. "You should consider attending a smoking cessation program." d. "Your coronary arteries could block and cause a heart attack."

B. "Many clients end up having to have an amputation, especially a leg." Smoking aggravates Buerger's disease. Aggravated or severe Buerger's disease can lead to arterial occlusion caused by superficial thrombophlebitis resulting in poor would healing and poor circulation. This can lead to the need for amputation. Buerger's disease affects the arteries and veins in the upper and lower extremities-- not the coronary arteries.

The nurse is caring for a client on strict bed rest. Which intervention is priority when caring for this patient? a. encourage them to drink fluids b. perform active range of motion exercises c. elevate the head of the bed to 45* d. provide a high fiber diet to the client

B. Perform active range of motion exercises Preventing deep vein thrombosis is the priority nursing intervention bc the client is on strict bed rest. Range of motion exercises should be done every four (4) hours.

The client diagnosed with subclavian steal syndrome has undergone surgery. Which assessment data would warrant immediate intervention by the nurse? a. The client's pedal pulse on the left leg is absent. b. The client complains of numbness in the right hand. c. The client's brachial pulse is strong and bounding. d. The client's capillary refill time (CRT) is less than three (3) seconds.

B. The client complains of numbness in the right hand. Subclavian steal syndrome affects the upper extremities only. Occurs from subclavian artery occlusion or stenosis; therefor any abnormal neurovascular assessment would warrant intervention

Which client behavior would be a causative factor for developing Buerger's disease? a. Drinking alcohol daily. b. Eating a high fat diet. c. Chewing tobacco d. Inhaling gasoline fumes

C. Chewing tobacco Heavy smoking or chewing tobacco is causative or an aggravating factor for Buerger's disease. Cessation of the disease process may occur with quitting tobacco use.

Which question should the nurse ask the male client diagnosed with aortoilliac disease during an admission interview? a. "Do you have trouble sitting for long periods of time?" b. "How often do you have a bowel movement or urinate?" c. "When you lie down, do you feel throbbing in your abdomen?" d. "Have you experienced any problems having sexual intercourse?"

D. "Have you experienced any problems having sexual intercourse?" Aortoilliac disease is caused by atherosclerosis of the aortoilliac arch which causes pain in the lower back, buttocks, and impotence in men.

62. Which assessment data would support that the client has a venous stasis ulcer? a. Superficial pink open area on the medial part of the ankle. b. A deep pale open area over the top side of the foot. c. A reddened blistered area on the heel of the foot. d. A necrotic gangrenous area on the dorsal side of the foot.

a. Superficial pink open area on the medial part of the ankle. The medial part of the ankle usually ulcerates bc of edema that leads to stasis, which in turn causes the skin to break down. Gangrene does not usually occur with venous problems, usually with arterial

A patient taking warfarin asks for an aspirin for a headache. What is the nurse's best action? a Administer 650 mg of acetylsalicylic acid (ASA) and reassess pain in 30 min. b Teach the patient of potential drug interactions with anticoagulants. c Explain to the patient that ASA is contraindicated and administer ibuprofen as ordered. d Explain that the headache is an expected side effect and will subside shortly.

b Teach the patient of potential drug interactions with anticoagulants. Patients taking an anticoagulant should not use medications that would further increase the risk of bleeding, which includes aspirin as well as ibuprofen. Aspirin should not be administered to the patient taking other anticoagulants, unless it is ordered specifically as a low-dose daily therapy. Ibuprofen is not the best choice of medication for the patient receiving warfarin. Acetaminophen would be preferred for pain relief. Headache is not an expected side effect of warfarin therapy.

40. The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment? a. "I have stomach pain every time I eat a big, heavy meal." b. "I don't have any abdominal pain or any type of problems." c. "I have periodic episodes of constipation and then diarrhea." d. "I belch a lot, especially when I lay down after eating."

b. "I don't have any abdominal pain or any type of problems." Only about 2/5ths of client with AAA have symptoms; the remainder are asymptomatic.

53. The client diagnosed with a DVT is placed on a medical unit. Which nursing interventions should be implemented? Select all that apply. a. Place sequential compression devices on both legs. b. Instruct the client to stay in bed and not ambulate. c. Encourage fluids and a diet high in roughage. d. Monitor IV site every shift and PRN. e. Assess Homans' sign every 24 hours.

b. Instruct the client to stay in bed and not ambulate. c. Encourage fluids and a diet high in roughage. d. Monitor IV site every shift and PRN. Clients should be on bed rest five to seven days after the diagnosis to allow time for the clot to adhere to the vein wall. Bed rest and limited activity predispose the patient to constipation; fluids and dietary fiber will prevent constipation. The IV heparin therapy should be monitored.

37. Which assessment data would the nurse recognize to suppor the diagnosis of abdominal aortic aneurysm (AAA)? a. shortness of breath b. abdominal bruit c. ripping abdominal pain d. decreased urinary output

b. abdominal bruit A systolic bruit over the abdomen is a diagnostic indication of an AAA.

39. Which client would be most likely to develop an abdominal aortic aneurysm? a. A 45-year-old female with a history of osteoporosis. b. An 80-year-old female with congestive heart failure. c. A 69-year-old male with peripheral vascular disease. d. A 30-year-old male with a genetic predisposition to AAA.

c. A 69-year-old male with peripheral vascular disease. The most common cause of AAA is atherosclerosis--which is the cause of peripheral vascular disease. It occurs in men 4x more often then women and primarily in Caucasians.

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? a. Glucose combines with carbon monoxide, instead of with oxygen, and this leads to oxygen deprivation of tissues b. Diabetes stimulates the sympathetic nervous system, resulting in peripheral constriction that increases the development of atherosclerosis c. Diabetes speeds the atherosclerotic process by thickening the basement membrane of both large and small vessels. d. The increased glucose combines with the hemoglobin, which causes deposits of plaque in the lining of the vessels.

c. Diabetes speeds the atherosclerotic process by thickening the basement membrane of both large and small vessels. Glucose does not combine with carbon monoxide. Vasoconstriction is not a risk factor. When glucose combines with hemoglobin in a laboratory test called glycosylated hemoglobin, the result can determine the client's average glucose level over the past 3 months (HbgA1C)

60. The client is being admitted with Coumadin (warfarin), an anticoagulant, toxicity. Which laboratory data should the nurse monitor? a. Blood urea nitrogen levels (BUN). b. Bilirubin levels. c. International Normalized Ratio (INR). d. Partial thromboplastin time (PTT).

c. International Normalized Ratio (INR). PT/INR= coumadin/ warfarin PTT= heparin

The nurse is assessing a client with chest pain to evaluate whether the client is suffering from angina or myocardial infarction (MI). Which symptom is indicative of an MI? a. Substernal chest discomfort occurring at rest b.Chest pain brought on by exertion or stress c. Substernal chest discomfort relieved by nitroglycerin or rest d. Substernal chest pressure relieved only by opioids

d. Substernal chest pressure relieved only by opioids Substernal chest pressure relieved only by opioids is typically indicative of MI.Substernal chest discomfort that occurs at rest is not necessarily indicative of MI, and it could be a sign of unstable angina. Both chest pain brought on by exertion or stress and substernal chest discomfort relieved by nitroglycerin or rest are indicative of angina.