Evolve Chapter 33
The nurse is teaching a client with peripheral arterial disease. What teaching will the nurse include? a) "Walk to the point of leg pain, then rest, resuming when pain stops." b) "Inspect your legs daily for brownish discoloration around the ankles." c) "Apply a heating pad to the legs if they feel cold." d) "Elevate your legs above heart level to prevent swelling."
a) "Walk to the point of leg pain, then rest, resuming when pain stops." Rationale: The teaching point the nurse include for a client with PAD is walk to the point of leg pain, rest, and then resume when pain stops. Exercise may improve arterial blood flow by building collateral circulation. Instruct the client to walk until the point of claudication, stop and rest, and then walk a little farther.Elevating the legs in PAD decreases blood flow and increases ischemia. Brown discoloration around the ankles is characteristic of venous disease. Application of heat must be avoided in clients with PAD due to a lack of sensation and possible burns to the legs.
For a client with an 8-cm abdominal aortic aneurysm, which assessment data must be addressed immediately? a) Blood pressure (BP) 192/102 mm Hg b) Report of constipation c) Anxiety d) Heart rate 52 beats/min
a) Blood pressure (BP) 192/102 mm Hg Rationale: The problem that must be addressed immediately in a client with an 8-cm abdominal aneurysm is a BP of 192/102 mm Hg. Elevated blood pressure can increase the rate of aneurysmal enlargement and risk for early rupture.The nurse must consider the client's usual pulse. However, bradycardia does not pose a risk for aneurysm rupture. Straining at stool can elevate blood pressure and pose a risk for dissection. However, a potential problem would not be addressed before an actual problem. Anxiety may be benign or may be a symptom of something serious. However, the elevated blood pressure is an immediate risk.
The nurse is assigned to all of these clients. Which client would the nurse assess first? a) The client who had percutaneous vascular intervention of the right femoral artery 30 minutes ago. b) The client admitted with hypertensive crisis who has a nitroprusside drip and blood pressure of 149/80 mm Hg. c) The client with peripheral vascular disease who has a left leg ulcer draining purulent yellow fluid. d) The client who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot.
a) The client who had percutaneous vascular intervention of the right femoral artery 30 minutes ago. Rationale: The client who would be assessed first is the client who had a percutaneous vascular intervention of the right femoral artery 30 minutes ago. This client must have checks of vascular status and vital signs every 15 minutes in the first hour after the procedure.The client admitted with hypertensive crisis has stabilized and is not in need of immediate assessment. The client with peripheral vascular disease is the most stable and can be seen last. The client who had a right femoral-popliteal bypass is not in need of immediate assessment and can be assessed after the client who had a percutaneous vascular intervention.
The nurse is caring for a client who had abdominal aortic aneurysm (AAA) repair. Which assessment data is most concerning to the nurse? a) Urine output of 20 mL over 2 hours b) Blood pressure of 106/58 mm Hg c) +3 pedal pulses d) Absent bowel sounds
a) Urine output of 20 mL over 2 hours Rationale: The nurse caring for a client who had an AAA repair would be most alarmed with the client's urine output of 20 mL over 2 hours. Complications post AAA stent repair include bleeding, which may manifest as signs of hypovolemia and oliguria.Reduction of systolic blood pressure to 100 to 120 mm Hg is appropriate. Paralytic ileus may be a complication of AAA repair, but is not a priority over decreased urine output. +3 pedal pulses is a normal physical assessment finding.
The nurse is caring for a client with dark-colored toe ulcers and blood pressure (BP) of 190/100 mm Hg. Which nursing action does the nurse delegate to the LPN/LVN? a) Obtain a request from the primary health care provider for a dietary consult. b) Administer a clonidine patch for hypertension. c) Develop a plan for discharge, and assess home care needs. d) Assess leg ulcers for signs of infection.
b) Administer a clonidine patch for hypertension. Rationale: The action the nurse delegates to the LPN/LVN caring for a client with dark-colored toe ulcers and a BP of 190/100 mm Hg is to administer a clonidine patch for hypertension. Administering medication is within the scope of practice for the LPN/LVN.The RN is responsible for physical assessments, making referrals for other services, and developing the plan of care for the hospitalized client.
The nurse is assessing a 54-year-old male client for risk of atherosclerosis. What assessment data is associated with an increase in risk? (Select all that apply.) a) Takes acetylsalicylic acid daily. b) BMI is 32. c) History of type 2 diabetes mellitus. d) LDL of 160 mg/dL. e) The client's father has lung cancer. f) Current smoking history.
b) BMI is 32. c) History of type 2 diabetes mellitus. d) LDL of 160 mg/dL. f) Current smoking history. Rationale: Risk factors that contribute to atherosclerosis include: an increase in LDL (160 mg/dL is high), obesity (as indicated by a BMI is 32), smoking, and type 2 diabetes.ASA is used as prophylaxis for atherosclerotic disease/coronary artery disease to prevent platelet adhesion. While atherosclerosis can be genetic, the fact that the client's father has lung cancer does not increase his risk for atherosclerosis.
The nurse is caring for a client who is being treated for hypertensive crisis. Which prescribed medication would the nurse question? a) Enalapril b) Dopamine c) Labetalol d) Sodium nitroprusside
b) Dopamine Rationale: The nurse would question the prescription for dopamine. Dopamine is used for its inotropic and vasoconstrictive properties to raise blood pressure, and would not be used in hypertensive crisis.Enalapril, an angiotensin-converting enzyme inhibitor, may be used intravenously in hypertensive emergencies. Sodium nitroprusside, a direct-acting vasodilator, may be used intravenously to lower blood pressure quickly in hypertensive emergencies. Labetalol, an intravenous calcium channel blocker, is used in hypertensive crisis when oral therapy is not feasible.
The nurse is teaching the client dietary methods to reduce LDL levels. What teaching will the nurse include? (Select all that apply.) a) Aim for 10% of calories from saturated fat b) Limit trans-fat intake. c) Emphasize the intake of whole grains. d) Avoid cooking with all oil. e) Nuts are a good snack food. f) Try to purchase skinless chicken to cook with.
b) Limit trans-fat intake. c) Emphasize the intake of whole grains. e) Nuts are a good snack food. f) Try to purchase skinless chicken to cook with. Rationale: The American Heart Association publishes dietary recommendations to decrease LDL levels. These recommendations include: emphasizing the intake of whole grains, vegetables, and fruits; consuming poultry without the skin; consuming low-fat dairy products and nuts; cooking with nontropical oils (e.g. Canola); limiting trans-fat intake and aiming for a dietary pattern that includes 5% to 6% of calories from saturated fat
The nurse is assessing a client with arterial insufficiency. What assessment data would cause the nurse to suspect an acute arterial occlusion of the right lower extremity? (Select all that apply.) a) Tachycardia b) Mottling of right foot and lower leg c) Bounding right pedal pulses d) Numbness and tingling of right foot e) Hypertension f) Cold right foot
b) Mottling of right foot and lower leg d) Numbness and tingling of right foot f) Cold right foot Rationale: Signs/symptoms of acute arterial occlusion of the right lower extremity include cold right foot, numbness and tingling of the right foot, and mottling and tingling of the right foot. Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of acute arterial occlusion.Hypertension presents risk for atherosclerosis, but not for acute arterial occlusion. The pulse rate does not indicate occlusion, but rather quality. Absence of pulse, rather than bounding pulse, is a symptom of acute arterial occlusion.
Which assessment by a new nurse requires the charge nurse to intervene? a) Assessing pedal pulses by Doppler b) Simultaneously palpating bilateral carotids c) Measuring blood pressure in both arms d) Measuring capillary refill in the fingertips
b) Simultaneously palpating bilateral carotids Rationale: The vascular assessment by the new nurse that requires intervention by the charge nurse is simultaneously palpating bilateral carotids. Carotid arteries are palpated separately because of the risk for inadequate cerebral perfusion and the risk for causing the client to faint.Prolonged capillary filling generally indicates poor circulation, and is an appropriate assessment. Many clients with vascular disease have poor blood flow. Pulses that are not palpable may be heard with a Doppler probe. Because of the high incidence of hypertension in clients with atherosclerosis, blood pressure is often assessed in both arms.
A new nurse is caring for four clients. Which client is at risk for secondary hypertension? a) The client who is physically inactive. b) The client with kidney disease. c) The client with depression. d) The client who eats a high-sodium diet.
b) The client with kidney disease. Rationale: The client who is most at risk for secondary hypertension is the client with kidney disease. Kidney disease is one of the most common causes of secondary hypertension.Some psychiatric conditions can exacerbate essential hypertension, but secondary hypertension is caused by a disease process or drugs. High-sodium intake is a risk factor for essential hypertension, not for secondary hypertension, which is caused by disease states or medications. Physical inactivity is a risk factor for essential hypertension.
The nurse is teaching a client the precautions to take while on warfarin therapy. Which client statement demonstrates that teaching has been effective? a) "I can use an electric razor or a regular razor." b) "When taking warfarin, I may notice some blood in my urine." c) "Eating foods like green beans won't interfere with my warfarin therapy." d) "If I notice I am bleeding a lot, I should stop taking warfarin right away."
c) "Eating foods like green beans won't interfere with my warfarin therapy." Rationale: Teaching about the precautions of warfarin has been effective when the client says "that eating foods like green beans won't interfere with my Coumadin therapy." Vitamin K is not found in foods such as green beans, so these foods will not interfere with the anticoagulant effects of Coumadin.Warfarin "thins" the blood, so the risk for cutting oneself and bleeding is very high with the use of a regular razor. The client needs to use an electric razor. Clients must apply pressure to bleeding wounds and must seek medical assistance immediately. While they may need to discontinue warfarin therapy, the priority is to apply pressure to the bleeding area and seek medical care. Blood in the urine of a client taking warfarin therapy is not a side effect. The client must notify the primary health care provider immediately if this occurs.
A client with peripheral arterial disease (PAD) has a percutaneous vascular intervention. What is the priority nursing assessment? a) Dye allergy b) Gag reflex c) Pedal pulses d) Ankle-brachial index
c) Pedal pulses Rationale: After a client with PAD has had a percutaneous vascular intervention, it is essential for the nurse to assess for pedal pulses. Priority nursing care focuses on assessment for bleeding at the arterial puncture site and monitoring distal pulses to ensure adequate perfusion. Pulse checks must be assessed postprocedure to detect improvement (stronger pulses) or complications (diminished or absent pulses).Ankle-brachial index is a diagnostic study used to detect the presence of PAD. This is not necessary after percutaneous vascular intervention. It is imperative to assess for dye allergy before performing the procedure. Gag reflex is checked after procedures affecting the throat (e.g., endoscopy, bronchoscopy).
The nurse in the cardiology clinic is reviewing teaching provided at the client's last appointment regarding hypertension management. Which actions by the client indicate that teaching has been effective? (Select all that apply.) a) Reports walking the neighborhood once weekly. b) Reports eating fast food frequently to cut down on food costs. c) Weight loss of 3 lb (1.4 kg) since last seen in the clinic. d) Reports eating a low-sodium diet. e) Reports drinking one less cup of coffee daily.
c) Weight loss of 3 lb (1.4 kg) since last seen in the clinic. d) Reports eating a low-sodium diet. e) Reports drinking one less cup of coffee daily. Rationale: Teaching about hypertension has been effective when the nurse notes that the client has been on a low-sodium, diet has lost 3 lb (1.4 kg) since the last clinic visit, and has cut down on caffeine. Clients with hypertension need to consume low-sodium foods and would avoid adding salt. Weight loss can result in lower blood pressure. Caffeine promotes vasoconstriction, thereby elevating blood pressure.Although eating out may be cost-saving, fast food is often higher in saturated fat. The goal is to exercise three times and not once weekly.
A client with hypertension is started on verapamil. What teaching will the nurse provide for this client? a) "Consume foods high in potassium." b) Monitor for muscle cramping." c) "Monitor for irregular pulse." d) "Avoid grapefruit juice."
d) "Avoid grapefruit juice." Rationale: The nurse teaches the client who is taking verapamil to avoid grapefruit juice. Grapefruit juice must be avoided with calcium channel blockers, such as verapamil, because it can enhance the action of the drug.Foods high in potassium would be encouraged for clients taking diuretics, not calcium channel blockers such as verapamil. Bradycardia, not irregular pulse, is a typical side effect of verapamil. Muscle cramping may occur with statins, not with calcium channel blockers.
When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? a) "I have a headache. May I have some acetaminophen?" b) "I have had hoarseness for a few weeks." c) I feel my heart beating in my abdominal area." d) "I just started to feel a pain in my belly and low back."
d) "I just started to feel a pain in my belly and low back." Rationale: The nurse suspects dissection of an AAA when the client says that "I just started to feel a tearing pain in my belly." Severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs, is indicative of impending rupture of AAA.The sensation of feeling the heartbeat in the abdomen is a symptom of AAA but not of dissection or rupture. Headache may be benign or indicative of cerebral aneurysm or increased intracranial pressure. Hoarseness, shortness of breath, and difficulty swallowing may be symptoms of thoracic aortic aneurysm.
Which client who has just arrived in the emergency department does the nurse assess as emergent and in need of immediate medical evaluation? a) A 64 year old with chronic venous ulcers who has a temperature of 100.1° F (37.8° C). b) A 60 year old with venous insufficiency who has new-onset right calf pain and tenderness. c) A 69 year old with a 40-pack-year cigarette history who is reporting foot numbness. d) A 70 year old with a history of diabetes who has "tearing" back pain and is diaphoretic.
d) A 70 year old with a history of diabetes who has "tearing" back pain and is diaphoretic. Rationale: The client who just arrived in the ED and needs immediate medical evaluation is the 70 year old with a history of diabetes who has "tearing" back pain and is diaphoretic. This client's history and clinical signs and symptoms suggest possible aortic dissection. The nurse will immediately assess the client's blood pressure and plan for IV antihypertensive therapy, rapid diagnostic testing, and possible transfer to surgery.The 64 year old is most stable and can be seen last. The 60 year old and the 69 year old would both be seen soon, but the 70-year-old client must be seen first.
A client is receiving unfractionated heparin (UFH) by infusion. What laboratory data will the nurse report to the primary health care provider (PCP)? a) Hemoglobin 12.2 g/dL (122 mmol/L) b) White blood cells 11,000/mm3 (11 × 109/L) c) Partial thromboplastin time (PTT) 60 seconds d) Platelets 32,000/mm3 (32 × 109/L)
d) Platelets 32,000/mm3 (32 × 109/L) Rationale: When caring for a client receiving UFH, the nurse notifies the PCP of a platelet level of 32,000/mm3 (32 × 109/L). UFH can decrease platelet counts. The PCP must be notified if the platelet count is below 100,000 to 120,000/mm3 (100 to 120 × 109/L).A 60-second PTT reflects a therapeutic value within 1.5 to 2 times the normal value. Mild leukocytosis (increased white blood cells) may be expected with deep vein thrombosis. A hemoglobin of 12.2 g/dL (122 mmol/L) reflects a normal reading.
The nurse is caring for a client with peripheral arterial disease (PAD). Which symptom will the nurse anticipate? a) Decreased pain when legs are elevated b) Unilateral swelling of affected leg c) Pulse oximetry reading of 90% d) Reproducible leg pain with exercise
d) Reproducible leg pain with exercise Rationale: The symptom the nurse assesses the client with PAD is reproducible leg pain with exercise. Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances.Unilateral swelling is typical of venous problems such as deep vein thrombosis. With PAD, pain decreases with legs in the dependent position. Pulse oximetry readings reflect the amount of oxygen bound to hemoglobin. PAD results from atherosclerotic occlusion of peripheral arteries.