Peripheral Vascular Disorders Practice Questions

The nurse is caring for a client receiving heparin sodium via constant infusion. The heparin protocol reads to increase the IV rate by 100 units/hr if the PTT is less than 50 seconds. The current PTT level is 46 seconds. The heparin comes in 500 mL of D5W with 25,000 units of heparin added. The current rate on the IV pump is 18 mL/hr. At what rate should the nurse set the pump?

Answer: 20 mL/hr To determine the rate, the test taker must first determine how many units are in each milliliter of fluid; 25,000 divided by 500 = 50 units of heparin in each milliliter of fluid, and 50 divided into 100 = 2, and 2 + 18 = 20. TEST-TAKING HINT: This math question is worked in several steps, but every step is a simple addition or division.

The nurse is caring for clients on a surgical floor. Which client should be assessed first? 1. The client is 4 days postoperative abdominal surgery and is reporting left calf pain when ambulating. 2. The client 1 day postoperative hernia repair has just been able to void 550 mL of clear amber urine. 3. The client is 5 days postoperative open cholecystectomy, has a T-tube, and is being discharged. 4. The client 16 hours postabdominal hysterectomy is reporting abdominal pain and is expelling flatus.

Answer: 1 1. A complication of immobility after surgery is developing a DVT. This client diagnosed with left calf pain should be assessed for a DVT. 2. This is an expected finding. 3. Clients requiring an open cholecystectomy frequently are discharged with a T-tube. This client needs to know how to care for the tube before leaving, but this is not a priority over a possible surgical complication. 4. This is expected for this client. TEST-TAKING HINT: In priority-setting questions, the test taker must decide if the information in the answer option is expected or abnormal for the situation. Based on this, options "2," "3," and "4" can be eliminated.

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. Sex. 4. Family history.

Answer: 1 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. 2. The client cannot do anything about getting older, so it cannot be modified. 3. Sex is a risk factor that cannot be changed. 4. Having a family history of coronary artery disease predisposes the client to a higher risk, but this cannot be changed by the client. TEST-TAKING HINT: The test taker needs to key in on adjectives when reading the stem of a question. The word "modifiable" should cause the test taker to select "stress" because it is the only answer option referring to something that can be changed or modified.

The nurse is discussing the pathophysiology of atherosclerosis with a client with a normal high-density lipoprotein cholesterol (HDLC) level. Which information should the nurse discuss with the client concerning HDLCs? 1. A normal HDLC is good because it has a protective action in the body. 2. The HDLC level measures the free fatty acids and glycerol in the blood. 3. HDLC are the primary transporters of cholesterol into the cell. 4. The client needs to decrease the amount of cholesterol and fat in the diet.

Answer: 1 1. A normal HDLC level is good because HDLC transports cholesterol away from the tissues and cells of the arterial wall to the liver for excretion. This helps decrease the development of atherosclerosis. 2. The normal HDLC level was the result of a test measuring high-density lipoproteins, not free fatty acids and glycerol in the blood, which are measured by the serum triglyceride level. Triglycerides are a source of energy. 3. Low-density lipoproteins (LDLCs), not HDLCs, are the primary transporters of cholesterol into the cell. They have the harmful effect of depositing cholesterol into the walls of the arterial vessels. 4. A normal HDLC level is good, and the client does not need to change the diet. TEST-TAKING HINT: If the test taker has no idea what the correct answer is, the test taker should look at the specific words in the answer options. Normal laboratory data would probably be good for the client; therefore, option "1" would be a probable correct answer.

Which assessment data would warrant immediate intervention by the nurse? 1. The client diagnosed with DVT reporting pain on inspiration. 2. The immobile client refusing to turn for the last 3 hours. 3. The client with an open cholecystectomy refuses to breathe deeply. 4. The client with an inguinal hernia repair who must void before discharge.

Answer: 1 1. A potentially life-threatening complication of DVT is a pulmonary embolus, which causes chest pain. The nurse should determine if the client has "thrown" a pulmonary embolus. 2. An immobile client should be turned at least every 2 hours, but a pressure area is not life-threatening. 3. This is expected in a client with a large upper abdominal incision. It hurts to breathe deeply. The nurse should address this but has some time. The life-threatening complication is a priority. 4. Clients with inguinal hernia repair often have difficulty voiding afterward. This is expected. TEST-TAKING HINT: The test taker should determine which option contains information that indicates a potentially life-threatening situation. This is the priority client.

The nurse is unable to assess a pedal pulse in the client diagnosed with peripheral arterial 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.

Answer: 1 1. An absent pulse is not uncommon in a client diagnosed with peripheral arterial disease, but the nurse must ensure that the feet can be moved and are warm, which indicates adequate blood supply to the feet. 2. To identify the location of the pulse, the nurse should use a Doppler device to amplify the sound, but it is not the first intervention. 3. This position will increase blood flow and may help the nurse palpate the pulse, but it is not the first intervention. 4. Cold can cause vasoconstriction and decrease the ability to palpate the pulse, and warming will dilate the arteries, helping the nurse find the pedal pulse, but it is not the first intervention. TEST-TAKING HINT: The stem asks the test taker to identify the first intervention, and the test taker should apply the nursing process and implement an assessment intervention.

Which assessment data would require immediate intervention by the nurse for the client 6 hours postoperative AAA repair? 1. Absent bilateral pedal pulses. 2. Reports of pain at the site of the incision. 3. Distended, tender abdomen. 4. An elevated temperature of 100°F.

Answer: 1 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. 2. The nurse would expect the client to have incisional pain 6 hours after surgery, so this is not a priority over a complication. 3. The nurse would expect the client to have a distended, tender abdomen as a result of postoperative edema. 4. A slightly elevated temperature would not be uncommon in a postsurgical client. TEST-TAKING HINT: Any time the test taker has an answer option that has the word "absent" in it, the test taker should determine if this is normal for any client and, if not, consider it for the correct answer, especially in this case where the stem is asking which information warrants immediate intervention.

The client had an AAA repair 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.

Answer: 1 1. Assessment is the first part of the nursing process and is the first intervention the nurse should implement. 2. Administering an antibiotic is an appropriate intervention, but it is not a priority over assessment. 3. The client should splint the incision when coughing and deep breathing to help decrease the pain, but this intervention is not a priority over assessment. 4. Ambulating the client as soon as possible is an appropriate intervention to help decrease complications from immobility, but it is not a priority over assessment. TEST-TAKING HINT: If the test taker has difficulty in determining the first intervention, the test taker should always rely on the nursing process and select the assessment intervention if the intervention is appropriate for the disease process or condition.

Which arterial anticoagulant medication would the nurse anticipate being prescribed for a client diagnosed with peripheral arterial disease? 1. Clopidogrel. 2. Streptokinase. 3. Protamine sulfate. 4. Enoxaparin.

Answer: 1 1. Clopidogrel (Plavix) is an arterial antiplatelet that prevents clots from occurring in the lower extremity arteries. 2. Streptokinase is an enzyme that breaks down existing clots, a "clot buster." 3. Protamine sulfate is the antidote for heparin. 4. Enoxaparin (Lovenox) is a subcutaneous LMWH and not usually administered for peripheral arterial disease. TEST-TAKING HINT: The test taker should be aware of commonly administered medications and which instructions apply. This will allow the test taker to make decisions as to the appropriate nursing actions to implement.

The nurse is discussing the importance of exercising with a client 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.

Answer: 1 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. 2. Isometric (weight-lifting) exercises help develop muscle mass, but this type of exercise does not help decrease complications of atherosclerosis. 3. A low-fat, low-cholesterol diet may help decrease plaque formation, but exercise will not do this. 4. Isotonic exercises, such as walking and swimming, promote the movement of glucose across the cell membrane, but this is not why such exercises are recommended for the prevention of atherosclerotic complications. TEST-TAKING HINT: The test taker must understand what the stem of the question is asking and note the words "the complications of atherosclerosis." "Isometric," which refers to "muscle" (remember "m"), and "isotonic," which refers to "tone" (remember "t"), exercises do not directly help prevent the complications of atherosclerosis, so options "2" and "4" can be eliminated.

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."

Answer: 1 1. Even if the client feels great, the BP can be elevated, causing damage to the heart, kidney, and blood vessels. 2. A headache may indicate an elevated BP, but the client diagnosed with essential hypertension can be asymptomatic and still have a very high BP reading. 3. This response does not answer the client's question as to why the doctor is worried about the client's BP. 4. The BP does not necessarily reflect how well the heart is working. Many other diagnostic tests assess how well the heart is working, including an electrocardiogram (ECG), an ultrasound, and a chest x-ray. TEST-TAKING HINT: The test taker should select the option that provides the client with correct information in a nonthreatening, nonjudgmental approach.

The client is admitted for surgical repair of an 8-cm AAA. Which clinical manifestation would make the nurse suspect the client has an expanding AAA? 1. Reports of low back pain. 2. Weakened radial pulses. 3. Decreased urine output. 4. Increased abdominal girth.

Answer: 1 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. 2. If any pulses were affected, it would be the pedal pulses, not the radial pulses. 3. Decreased urine output would not indicate an expanding AAA, but decreased urine output may occur when the AAA ruptures, causing hypovolemia. 4. The abdominal girth would not increase for an expanding AAA, but it might increase with a ruptured AAA. TEST-TAKING HINT: If the test taker knows the anatomical position of the abdominal aorta and understands the term "expanding," then it may lead the test taker to select low back pain as the correct answer.

The UAP is caring for the client diagnosed with chronic venous insufficiency. Which action would warrant immediate intervention from the RN? 1. Removing compression stockings before assisting the client to bed. 2. Taking the client's BP manually after using the machine. 3. Assisting the client by opening the milk carton on the lunch tray. 4. Calculating the client's shift intake and output with a pen and paper.

Answer: 1 1. Research shows that removing the compression stockings while the client is in bed promotes perfusion of the subcutaneous tissue. The foot of the bed should be elevated. 2. The UAP can take the BP with a machine or manually; therefore, the nurse would not need to intervene. 3. The UAP can help the client with meals as long as the client is stable. 4. The UAP can calculate the intake and output, but the nurse must evaluate the data to determine if they are normal for the client. TEST-TAKING HINT: This is a backward "except" question. Flipping the question and asking which actions would be appropriate for the UAP to implement might make it easier for the test taker to answer the question.

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 to five 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 glasses of whole milk a day." 4. "I should decrease my grain intake to no more than twice a week."

Answer: 1 1. The DASH diet has proved beneficial in lowering BP. It recommends eating a diet high in vegetables, fruits, and whole grains (National Heart, Lung, and Blood Institute, n.d.). 2. The DASH diet recommends two or fewer servings of lean meats, which have very few white streaks; the white streaks indicate the meat is high in fat. 3. The DASH diet recommends two to three servings of nonfat or low-fat milk, not whole milk. 4. The DASH diet recommends six to eight servings of grain a day. TEST-TAKING HINT: The test taker is looking for correct information about the DASH diet. A recommended diet for hypertension would limit fatty meats and whole milk.

The nurse is caring for a client diagnosed with DVT. Which information reported to the RN by the UAP requires immediate intervention? 1. The UAP informed the nurse the client is reporting chest pain. 2. The UAP notified the nurse the client's BP is 100/66. 3. The UAP reported the client is requesting to be able to take a shower. 4. The UAP tells the nurse the client is asking for medication for a headache.

Answer: 1 1. The UAP has informed the nurse that a client is having chest pain. A DVT can break loose and become an embolism, which can cause life-threatening problems for the client. 2. The BP is within normal limits (WNL). 3. This is not an unusual request, and the nurse should discuss the need for limited activity, but it does not require immediate intervention. 4. A headache is not life-threatening. It does not require immediate intervention. TEST-TAKING HINT: The test taker should consider which could be the most serious of the situations listed for the client. This is the one that requires immediate intervention.

Which client problem would be a priority in a client diagnosed with peripheral arterial disease, admitted to the hospital with a foot ulcer? 1. Impaired skin integrity. 2. Activity intolerance. 3. Ineffective health maintenance. 4. Risk for peripheral neuropathy.

Answer: 1 1. The client has a foot ulcer; therefore, the protective lining of the body—the skin—has been impaired. 2. This is an appropriate problem but would not take priority over impaired skin integrity. 3. The client needs teaching, but it does not take priority over a physiological problem. 4. The client has peripheral neuropathy, not a risk for it; this is the primary pathological change in a client diagnosed with peripheral arterial disease. TEST-TAKING HINT: Remember Maslow's hierarchy of needs; physiological needs are a priority.

The nurse is assessing the client diagnosed with long-term peripheral arterial 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.

Answer: 1 1. The decreased oxygen over time causes the loss of hair on the tops of the feet and ascending both legs. 2. The toenails are usually thickened as a result of hypoxemia. 3. Petechiae are tiny purple or red spots that appear on the skin as a result of minute hemorrhages within the dermal layer; this does not occur with peripheral arterial disease. 4. There may be edema, but it is usually pitting; nonpitting edema resolves with elevation but not in clients diagnosed with peripheral arterial disease. TEST-TAKING HINT: The test taker should apply the pathophysiological concept that arterial blood supplies oxygen and nutrients, and if the hair cannot get nutrients, it will not grow.

Which assessment data would support that the client has a venous stasis ulcer? 1. A superficial pink open area on the medial part of the ankle. 2. A deep pale open area over the top side of the foot. 3. A reddened, blistered area on the heel of the foot. 4. A necrotic gangrenous area on the dorsal side of the foot.

Answer: 1 1. The medial part of the ankle usually ulcerates because of edema that leads to stasis, which, in turn, causes the skin to break down. 2. A deep, pale, open area over the top side of the foot describes an arterial ulcer. 3. A reddened, blistered area on the heel describes a blister that may result from wearing shoes that are too tight or that rub on the heel. 4. Gangrene does not usually occur with venous problems; it occurs with arterial ulcers. TEST-TAKING HINT: There are some questions that require the test taker to be knowledgeable of the disease process.

The client diagnosed with a DVT is on a heparin drip at 1,400 units per hour, and warfarin 5 mg daily. Which intervention should the nurse implement first? 1. Check the PTT and PT/INR. 2. Check with the HCP to see which drug should be discontinued. 3. Administer both medications. 4. Discontinue the heparin because the client is receiving warfarin.

Answer: 1 1. The nurse should check the laboratory values pertaining to the medications before administering the heparin and warfarin (Coumadin), both anticoagulant medications. 2. The client will be administered an oral medication while still receiving a heparin drip to allow time for the client to achieve a therapeutic level of the oral medication before discontinuing the heparin. The effects of oral medications take 3 to 5 days to become therapeutic. 3. The laboratory values should be noted before administering the heparin and warfarin (Coumadin), both anticoagulant medications. 4. The heparin will be continued for 3 to 5 days before being discontinued. TEST-TAKING HINT: Knowing the actions of each medication, as well as the laboratory tests that monitor the safe range of dosing, is important. Remember, assessment is first. Assess blood levels and then administer the medication.

The client on the telemetry unit is diagnosed with thromboembolism and is reporting chest pain and anxiety. Which action should the RN implement first? 1. Stay with the client and call the rapid response team (RRT). 2. Assess the client's vital signs. 3. Have the UAP stay with the client. 4. Check the client's telemetry reading.

Answer: 1 1. These clinical manifestations could indicate a pulmonary embolus. The nurse should not leave the client but should get help as soon as possible. The rules of the RRT are that anyone can call an RRT if a concern is noted, and no one will suffer consequences if one was called and it was determined that the client was not in serious danger. 2. The nurse's first action is to stay with the client and call for help. 3. The UAP cannot be assigned an unstable client. 4. The telemetry reading is not important in regard to the current clinical manifestations. TEST-TAKING HINT: Remember, "if in distress, do not assess"; the nurse must implement an intervention that will directly affect the client outcome.

The client diagnosed with varicose veins asks the nurse, "What caused me to have these?" Which statement by the nurse would be most appropriate? 1. "You have incompetent valves in your legs." 2. "Your legs have decreased oxygen to the muscle." 3. "There is an obstruction in the saphenous vein." 4. "Your blood is thick and can't circulate properly."

Answer: 1 1. Varicose veins are irregular, tortuous veins with incompetent valves that do not allow the venous blood to ascend the saphenous vein. 2. Decreased oxygen to the muscle occurs with arterial occlusive disease. 3. This is the explanation for a DVT. 4. Thick, poorly circulating blood could be an explanation for diabetic neuropathy. TEST-TAKING HINT: Knowing that veins have valves and arteries do not might help the test taker select the correct answer. The test taker should use knowledge of anatomy and physiology to determine the answer.

Which client would be most at risk for developing varicose veins? 1. A female nurse. 2. A male bus driver. 3. A female with no children. 4. An elderly male with diabetes.

Answer: 1 1. Varicose veins are more common in females, Hispanic ethnicity, increasing age, obesity, and in occupations that involve prolonged standing or sitting. 2. Driving a bus requires prolonged sitting, which is a risk factor for developing varicose veins, but women are more prone to developing varicose veins. 3. Studies suggest that the increased risk for varicose veins is common during pregnancy and may be the result of venous stasis. 4. Diabetes may lead to diabetic neuropathy and arterial occlusive disease, but it does not lead to varicose veins. TEST-TAKING HINT: The test taker must know that prolonged standing or sitting, occupations that have people on their feet for long periods of time, female sex, Hispanic ethnicity, increasing age, and obesity are risk factors for varicose veins.

Which medical treatment would be prescribed for the client diagnosed with an AAA less than 3 cm? 1. Ultrasound every 6 months. 2. Intravenous pyelogram yearly. 3. Assessment of abdominal girth monthly. 4. Repair of abdominal aortic aneurysm.

Answer: 1 1. When the aneurysm is small (less than 5 cm), an abdominal sonogram will be done every 6 months until the aneurysm reaches a size at which surgery to prevent rupture is of more benefit than possible complications of an AAA repair. 2. An intravenous pyelogram evaluates the kidney. 3. The abdomen will not distend as the AAA enlarges. 4. This AAA is too small to perform surgery to remove it. TEST-TAKING HINT: The AAA less than 3 cm should make the test taker assume surgery is not an option; therefore, option "4" could be ruled out as a correct answer. Pyelo- means "kidney," so option "2" could be ruled out. The term "medical treatment" in the stem of the question should cause the test taker to rule out abdominal girth.

Which should the nurse include in the plan of care for a client diagnosed with venous stasis ulcers? Select all that apply. 1. Elevate the legs while sitting. 2. Wear antiembolism compression stockings. 3. Avoid injury to the lower limbs. 4. Trim the toenails straight across. 5. Do not apply moisturizer to the lower legs. 6. Allow the legs to hang over the bed in a dependent position.

Answer: 1, 2, 3, 4 1. Elevating the legs will assist the blood in returning to the heart. 2. Antiembolism stockings compress the veins and prevent stasis in the legs. 3. The circulation in the legs is compromised. Injuries will take longer to heal. 4. Trimming the toenails straight across prevents ingrown toenails. 5. The client may apply moisturizer to the legs. 6. The legs being in a dependent position applies to clients diagnosed with peripheral arterial disease. This assists the arterial flow to the feet. The problem with venous stasis is getting the blood back to the heart; the feet should be elevated. TEST-TAKING HINT: When answering a "Select all that apply" question, the test taker should read each option as a true or false option. If the option is true, then the test taker should choose it. All of the options may be correct or only one may be. By knowing the pathophysiology of blood circulation, the test taker can choose option "1" because venous circulation is returning blood to the heart. The test taker could eliminate option "6" because it is the opposite of option "1."

The nurse is demonstrating the use of a BP 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 HCP if the BP is >160/100. 3. Instruct the client about orthostatic hypotension. 4. Encourage the client to keep a record of the BP readings. 5. Explain that even when the BP is within normal limits, the medication should still be taken.

Answer: 1, 2, 3, 4, 5 1. BP 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 BP is not controlled, and the medication regimen might need to be adjusted. 3. Antihypertensive medications can cause a drop in the BP 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 BP 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. TEST-TAKING HINT: The test taker should be aware of commonly administered medications and which instructions apply. This will allow the test taker to make decisions as to the appropriate nursing actions to implement.

The nurse is completing a neurovascular assessment on the client diagnosed with chronic venous insufficiency. What should be included in this assessment? Select all that apply. 1. Assess for paresthesia. 2. Assess for pedal pulses. 3. Assess for paralysis. 4. Assess for pallor. 5. Assess for polar (temperature).

Answer: 1, 2, 3, 4, 5 1. The nurse should determine if the client has any numbness or tingling. 2. The nurse should determine if the client has pulses, the presence of which indicates there is no circulatory compromise. 3. The nurse should determine if the client can move the feet and legs. 4. The nurse should determine if the client's feet are pink or pale. 5. The nurse should assess the feet to determine if they are cold or warm. TEST-TAKING HINT: These five assessment interventions, along with assessing for pain, are known as the 6 Ps, which is the neurovascular assessment.

The client is diagnosed with a small AAA. Which interventions should be included in the discharge teaching? Select all that apply. 1. Tell the client to exercise three 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.

Answer: 1, 2, 4 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 the development of atherosclerosis. 3. The client should not decrease tobacco use—instead, the client must quit totally. Smoking is the one modifiable risk factor that is not negotiable. 4. Losing weight will help decrease the pressure on the AAA and will help address decreasing the cholesterol level. 5. A truss is worn by a client diagnosed with a hernia, not an AAA. TEST-TAKING HINT: "Select all that apply" questions are an alternate-type question that requires the nurse to select all interventions that are applicable to the question. The NCLEX-RN® does not give partial credit; the test taker must select all appropriate answers to receive credit for the question.

The nurse is teaching the client diagnosed with peripheral artery 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. Avoid crossing the legs. 5. Wear clean white cotton socks.

Answer: 1, 2, 4, 5 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. 3. Shoes should be purchased in the afternoon when the feet are the largest. 4. Crossing the legs will decrease circulation to the legs. 5. Colored socks have dyes, and dirty socks may cause foot irritation that may lead to breaks in the skin. TEST-TAKING HINT: The test taker must select all appropriate interventions; option "3" could be eliminated as a correct answer because of "only," which is an absolute word. There are very few absolutes in health care.

The nurse is teaching the client diagnosed with DVT and prescribed warfarin. Which should the nurse teach the client? Select all that apply. 1. Keep a constant amount of green, leafy vegetables in the diet. 2. Instruct the client to have regular INR laboratory work done. 3. Tell the client to go to the hospital immediately for any bleeding. 4. Inform the client to notify the HCP if having dark, tarry stools. 5. Encourage the client to carry medication regimen information. 6. Have the client take iron orally to prevent bleeding.

Answer: 1, 2, 4, 5 1. Green, leafy vegetables contain vitamin K, which is the antidote for warfarin; when achieving a therapeutic range for the INR, a change in the consumption of green, leafy vegetables will change the anticoagulant effects on the body. 2. The INR is the level that the HCP will use to gauge the anticoagulant effects occurring in the body and should be monitored regularly. 3. The nurse should teach the client to apply pressure on any bleeding for 5 minutes to see if a minor cut will stop bleeding on its own. The client should not go to the hospital unless bleeding cannot be stopped. 4. Dark, tarry stools indicate upper GI bleeding, and the HCP should be informed. 5. The client should carry information describing the client's medication regimen and inform any HCPs before lab tests, procedures, or surgery. 6. Iron does not prevent bleeding. TEST-TAKING HINT: When answering a "Select all that apply" question, the test taker should read each option as a true or false option. If the option is true, then the test taker should choose it. All of the options may be correct or only one may be.

Which interventions should the nurse include and teach 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. Teach the client that daily exercises are important.

Answer: 1, 2, 5 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. 3. A sedentary lifestyle should be discouraged; daily walking or swimming is encouraged. 4. This is an unrealistic intervention. The nurse needs to help the client learn ways to deal with stressful situations, not avoid the situations. 5. Daily exercise, such as walking or swimming, should be encouraged. TEST-TAKING HINT: This type of alternate question requires the test taker to select all answer options that apply. Some interventions are universal to all teaching, such as including significant others. Be careful with words such as "avoid."

The nurse is teaching the client recently diagnosed with essential hypertension. Which instruction should the nurse provide when discussing heart-healthy exercise? Select all that apply. 1. Walk briskly for at least 30 minutes a day on flat surfaces. 2. Perform heavy weightlifting three times a week. 3. Recommend high-intensity aerobics every day. 4. Encourage the client to swim laps once a week. 5. Use resistance bands at home at least twice a week.

Answer: 1, 5 1. Brisk walking 30 to 45 minutes a day will help to reduce BP, weight, and stress and will increase a feeling of overall well-being (American Heart Association, 2018). 2. Heavy weight lifting should be discouraged because performing this activity can raise systolic BP, although the research is controversial and can be addressed on an individual client basis. 3. The client should walk, cycle, jog, or swim as moderate-intensity aerobic activity on most days, but high-level aerobic exercise is recommended at least 2 days a week. 4. Swimming laps is recommended, but it should be daily, not once a week. 5. The use of resistance bands, a form of muscle-strengthening exercise, should be encouraged at least twice a week. TEST-TAKING HINT: Remember to look at the frequency of interventions; it makes a difference when selecting the correct answers.

Which actions should the surgical scrub nurse take to prevent personally developing a DVT? 1. Keep the legs in a dependent position and stand as still as possible. 2. Flex the leg muscles and change the leg positions frequently. 3. Wear white socks and shoes that have an elevated heel. 4. Ask the surgeon to allow the nurse to take a break midway through each surgery.

Answer: 2 1. Keeping the legs dependent and standing still will promote the development of a DVT. 2. Flexing the leg muscles and changing positions assist the blood in returning to the heart and move out of the peripheral vessels. 3. The nurse should wear support stockings, not socks, and change the types of shoes worn from day to day, varying the type of heels. 4. This is not in the client's best interest. TEST-TAKING HINT: The test taker can eliminate option "4" by imagining the reaction of the HCP if this were done. The words "dependent" and "still" make option "1" wrong.

The nurse is discussing discharge teaching with the client 3 days postoperative AAA repair. Which discharge instructions should the nurse include when teaching the client? Select all that apply. 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. 5. Hold a pillow to the incision when you cough or sneeze.

Answer: 1, 5 1. Redness or irritation of the incision indicates an infection and should be reported immediately to the HCP. 2. The client should not lift anything heavier than 5 pounds because it may cause dehiscence or evisceration of the bowel. 3. The pain medication should keep the client comfortable; if it doesn't, the client should call the HCP. 4. Some clients do not have daily bowel movements, but the nurse should instruct the client not to become constipated, which will increase pressure on the incision. 5. The client should continue to splint the incision with a pillow when coughing or sneezing to protect the incision and to decrease discomfort. TEST-TAKING HINT: The test taker should use basic concepts to answer questions. Clinical manifestations of incisional infection or systemic infection should always be reported to the HCP. Remember, the test taker should not eliminate an option as a possible answer just because it appears too easy an answer.

The intensive care unit nurse is calculating the total intake for a client diagnosed with a hypertensive crisis. What is the total intake for this client? Intake and Output Record - Oral (oz): Water (8 oz), Milk (4 oz), Chicken broth (6 oz) - Intravenous (mL): 680 mL (D5W), 100 mL (0.9% NS), 200 mL (D5W) - Urine (mL): 1,480 mL

Answer: 1,520 mL total intake The urinary output is not used in this calculation. The nurse must add up both intravenous fluids and oral fluids to obtain the total intake for this client: 680 + 100 + 200 = 980 IV fluids Oral fluids (1 ounce = 30 mL): 8 ounces × 30 mL = 240 mL, 4 ounces × 30 mL = 120 mL, 6 ounces × 30 mL = 180 mL 240 + 120 + 180 = 540 mL oral fluids Total intake is 980 + 540 = 1,520 mL.

The client diagnosed with a DVT is prescribed a heparin drip. The solution is 40,000 units in 500 mL of D5W. The HCP ordered the client to receive 1,200 units per hour. At which rate should the nurse set the IV pump?

Answer: 15 mL per hour. The nurse must first determine how many units are in each milliliter of fluid. 40,000 ÷ 500 mL = 80 units per milliliter. Next, the nurse must determine how many milliliter should be administered each hour: 1200 ÷ 80 = 15 mL per hour. TEST-TAKING HINT: The test taker should be aware of common mathematical equations in order to administer the correct dose of medication.

The client diagnosed with varicose veins is 6 hours postoperative vein ligation. Which nursing intervention should the nurse implement first? 1. Assist the client to dangle the legs off the side of the bed. 2. Assess and maintain pressure bandages on the affected leg. 3. Apply a sequential compression device to the affected leg. 4. Administer the prescribed prophylactic intravenous antibiotic.

Answer: 2 1. Because the saphenous vein is removed during vein ligation, standing and sitting are prohibited during the initial recovery period to prevent increased pressure in the lower extremities. 2. Pressure bandages are applied for up to 6 weeks after vein ligation to help prevent bleeding and to help venous return from the lower extremities when in the standing or sitting position. 3. Sequential compression devices are used to help prevent DVT. 4. Antibiotics would be ordered prophylactically for surgery, but it is not the first intervention. TEST-TAKING HINT: When the question asks the test taker to implement the first intervention, two or more of the answer options could be possible interventions, but only one is implemented first. Apply the nursing process and select the intervention that addresses assessment, which is the first part of the nursing process.

The nurse is admitting a client diagnosed with peripheral vascular disease. Which data support a diagnosis of venous insufficiency? 1. The client has bright red skin on the lower extremities. 2. The client has a brownish-purple area on the lower legs. 3. The client reports pain after ambulating for short distances. 4. The client has nonhealing wounds on the toes and ankles.

Answer: 2 1. Bright red tissue indicates an arterial problem. 2. Purplish-brown areas on the skin indicate venous stasis of the blood in the legs. 3. This indicates arterial occlusive disease. 4. This could indicate diabetic foot ulcers but does not mean venous problems. TEST-TAKING HINT: The test taker should apply pathophysiology knowledge to answer this question. Venous blood is darker than arterial blood, which is a brighter red.

The nurse is teaching a class to clients diagnosed with hypertension. Which should the nurse teach the clients? 1. The BP 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.

Answer: 2 1. Clients diagnosed with hypertension must have had a BP of 140/90 on three separate occasions unless the client has diabetes, and the BP reading is 135/85. The numbers may reach much higher levels. Over 160 systolic and 90 to 95 diastolic places the client at risk for cardiovascular events. The client's BP should be controlled according to the HCP instructions but 120/80 is not a realistic goal. 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. 3. The client should be taught to rise slowly from a recumbent position to prevent dizziness and falls. 4. The client should limit sodium in the diet to less than 2,300 mg/day. TEST-TAKING HINT: The test taker should be aware of commonly administered medications and which instructions apply. This will allow the test taker to make decisions as to the appropriate nursing actions to implement.

Which complication of anticoagulant therapy should the nurse teach the client to report to the HCP? 1. Gastric upset. 2. Bleeding from any site. 3. Constipation. 4. Myocardial infarction.

Answer: 2 1. Gastric upset is not an issue for a client receiving anticoagulant therapy. 2. Anticoagulant therapy reduces the client's ability to form clots; bleeding is the most important issue to discuss with the client. 3. Constipation is not caused by anticoagulant therapy. 4. Myocardial infarction is not caused by anticoagulant therapy, but it could be prevented by it. TEST-TAKING HINT: When answering questions about medications, the nurse must be aware of common instructions. In the case of any medication that involves changing the body's ability to form a clot, bleeding must always be an issue.

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 BP is 148/92. 4. The client's serum potassium level is 4.5 mEq.

Answer: 2 1. Normal sinus rhythm indicates that the client's heart is working normally. 2. Rapid weight gain—for example, 2 kg in 1 to 2 days—indicates that the loop diuretic is not working effectively; 2 kg equals 4.4 lb; 1 L of fluid weighs 1 kg. 3. This BP is not life-threateningly high and does not require immediate intervention. 4. Loop diuretics cause an increase in potassium excretion in the urine; therefore, the potassium level should be assessed, but 4.5 mEq/L is within normal limits (3.5 to 5.3 mEq/L). TEST-TAKING HINT: The phrase "requires immediate intervention" should make the test taker think that the correct answer will be abnormal assessment data that require medical intervention or indicate conditions that are life-threatening.

The client comes to the clinic reporting 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.

Answer: 2 1. Peripheral vascular disease is a broad term that encompasses both venous and arterial peripheral problems of the lower extremities. 2. This is the classic symptom of peripheral arterial disease. 3. This is characterized by calf tenderness, calf edema, and a positive Homans' sign. 4. This term is a clinical manifestation of peripheral arterial disease; the legs are pale when elevated but are dark red when in the dependent position. TEST-TAKING HINT: The test taker could eliminate options "1" and "3" as possible answers if the words "medical term" were noted. Both options "1" and "3" are disease processes, not medical terms.

The nurse is teaching a class on essential hypertension. Which modifiable risk factors would the nurse include when preparing this presentation? 1. Include information on retinopathy and nephropathy. 2. Discuss a sedentary lifestyle and smoking cessation. 3. Include discussions on family history and sex. 4. Provide information on a low-fiber and high-salt diet.

Answer: 2 1. Retinopathy and nephropathy are complications of uncontrolled hypertension, not modifiable risk factors. 2. A sedentary lifestyle is discouraged in clients diagnosed with hypertension; daily isotonic exercises are recommended. Smoking (cigars cause problems too) increases the atherosclerotic process in and causes vasoconstriction of vessels. Carbon monoxide adheres to hemoglobin, decreasing oxygen levels. 3. Family history and sex are nonmodifiable risk factors. The question is asking for information on modifiable risk factors. 4. A low-salt diet is recommended because increased salt intake causes water retention, which increases the workload of the heart. A high-fiber diet is recommended because it helps decrease cholesterol levels. TEST-TAKING HINT: Remember to look at the adjectives. The stem of the question is asking about "modifiable risk factors."

Which assessment data would the nurse recognize to support the diagnosis of an AAA? 1. Shortness of breath. 2. Abdominal bruit. 3. Ripping abdominal pain. 4. Decreased urinary output.

Answer: 2 1. Shortness of breath indicates a respiratory problem or possibly a thoracic aneurysm, not an AAA. 2. A systolic bruit over the abdomen is a diagnostic indication of an AAA. 3. Ripping or tearing pain indicates a dissecting aneurysm. 4. Urine output is not diagnostic of an AAA. TEST-TAKING HINT: The test taker with no idea of the answer should note that two of the options—"2" and "3"—have the word "abdominal" and choose between them, ruling out options "1" and "4," both of which refer to other systems of the body (respiratory and urinary).

The RN is caring for clients on a telemetry floor. Which nursing task would be most appropriate to delegate to a UAP? 1. Teach the client how to perform a glucometer check. 2. Assist feeding the client diagnosed with 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.

Answer: 2 1. Teaching cannot be delegated to a UAP. 2. The UAP can feed a client. 3. The UAP cannot assess the client and does not have the education to interpret laboratory data. 4. A unit of blood must be checked by two registered nurses at the bedside. TEST-TAKING HINT: Many states have rules concerning what tasks can be delegated to UAPs, but even those states that don't have delegation rules agree that teaching and assessing an unstable client cannot be delegated to UAPs.

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 verbalize feelings about the blood test result.

Answer: 2 1. The cholesterol level should be less than 200 mg/dL. 2. The client needs to be taught ways to lower the cholesterol level. 3. The client should be taught a low-fat, low-cholesterol diet to help lower the cholesterol level. 4. The nurse needs to discuss facts concerning the cholesterol level and teach the client. A therapeutic conversation would not be appropriate. TEST-TAKING HINT: The nurse needs to know normal laboratory test findings. The test taker unaware of normal cholesterol levels could only guess the answer to the question.

Which HCP's order should the nurse question in a client diagnosed with an expanding AAA scheduled for surgery in the morning? 1. Type and crossmatch for 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.

Answer: 2 1. The client is at risk for bleeding; therefore, this order would not be questioned. 2. Increased pressure in the abdomen secondary to a tap water enema could cause the AAA to rupture. 3. The client should be able to ambulate to the bathroom without any problems. 4. Clients are NPO before surgery to help prevent aspiration or problems from general anesthesia. TEST-TAKING HINT: An expanding AAA should cause the test taker to realize that no additional pressure should be placed on the AAA and that, therefore, selecting option "2" would be the most appropriate answer. Options "1," "3," and "4" would be appropriate for a client scheduled for an AAA repair or most types of surgeries. Remember basic concepts.

The nurse is caring for the client diagnosed with chronic venous insufficiency. Which statement indicates the client understands the discharge teaching? 1. "I shouldn't cross my legs for more than 15 minutes." 2. "I need to elevate the foot of my bed while sleeping." 3. "I should take a low-dose acetylsalicylic acid every day with food." 4. "I should increase my fluid intake to 3,000 mL a day."

Answer: 2 1. The client should not cross the legs at all because this further impedes the blood from ascending the saphenous vein. 2. Elevating the foot of the bed while sleeping helps the venous blood return to the heart and decreases pressure in the lower extremity. 3. Antiplatelet therapy, low-dose acetylsalicylic acid (baby aspirin), is for arterial blood, not venous blood. 4. Fluid intake will not help prevent or improve chronic venous insufficiency. TEST-TAKING HINT: Knowing about the venous and arterial blood systems will help the test taker eliminate or identify the correct answer. Venous blood goes back to the heart, so elevating the feet will help return it. Options "3" and "4" do not have anything to do with the extremities.

The client is 1 day postoperative AAA repair. Which information from the UAP would require immediate intervention from the RN? 1. The client refuses to turn from the back to the side. 2. The client's urinary output is 90 mL in 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.

Answer: 2 1. The nurse needs to intervene, but it does not require immediate intervention. 2. The client must have 30 mL of urinary output every hour. Clients post-AAA repair are at high risk for renal failure because of the anatomical location of the AAA near the renal arteries. 3. The client can sit on the bed the first day postoperation; this is, in fact, encouraged. 4. These vital signs would not warrant immediate intervention by the nurse. TEST-TAKING HINT: A basic concept that the test taker should remember is that any urine output less than 30 mL/hr should be cause for investigation.

The 80-year-old client is being discharged home after having surgery to débride a chronic venous ulcer on the right ankle. Which referral would be most appropriate for the client? 1. Occupational therapist. 2. Social worker. 3. Physical therapist. 4. Cardiac rehabilitation.

Answer: 2 1. The occupational therapist assists the client with activities of daily living skills, such as eating, bathing, or brushing teeth. 2. The social worker would assess the client to determine if home health-care services or financial interventions were appropriate for the client. The client is older, immobility is a concern, and wound care must be a concern when the client is discharged home. 3. The physical therapist addresses gait training and transferring. 4. Cardiac rehabilitation helps clients after myocardial infarctions, cardiac bypass surgery, or congestive heart failure recover. TEST-TAKING HINT: The test taker must be aware of the responsibilities of other members of the health-care team. "Discharge" is the keyword in the stem. The test taker should select an answer that will help the client in the home.

The spouse of a client diagnosed with peripheral arterial 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."

Answer: 2 1. The pain stops when the client quits walking; therefore, it is not rest pain. 2. Rest pain indicates a worsening of the peripheral arterial disease; the muscles of the legs are not getting enough oxygen when the client is resting to prevent muscle ischemia. 3. This is a therapeutic response and does not answer the spouse's question. 4. Rest pain indicates that the peripheral arterial disease is getting worse. TEST-TAKING HINT: The nurse should answer questions with factual information; therefore, option "3" could be eliminated as a possible answer. Pain usually does not indicate that a condition is getting better, which would cause the test taker to eliminate option "4."

The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which intervention should the nurse implement? 1. Notify the HCP 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 BP while the client is lying, standing, and sitting.

Answer: 2 1. The potassium level is within normal limits (3.5 to 5.3 mEq/L), and it is not usually checked before administering beta blockers. 2. The nurse should question administering the beta blocker if the BP is low because this medication will cause the BP to drop even lower, leading to hypotension. 3. The nurse would not administer the medication if the apical (not radial) pulse were less than 60 beats per minute. 4. The nurse needs to assess the BP only once before administering the medication (not take all three BPs before administering the medication). TEST-TAKING HINT: Be sure to read the entire question and all the answer options and note the specific numbers that are identified. The test taker must know normal laboratory data and assessment findings.

The 66-year-old male client has his blood pressure (BP) checked at a health fair. His BP is 168/98. Which action should the nurse implement first? 1. Recommend that the client have his BP checked in 1 month. 2. Instruct the client to see his health-care provider (HCP) 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 older person.

Answer: 2 1. This BP is elevated, and the client should have his BP checked frequently but not before seeking medical treatment. 2. The diastolic BP should be less than 80 mm Hg, according to the American Heart Association (2017); therefore, this client should see the HCP. 3. Teaching is important, but the nurse must first make sure the client sees the HCP for a thorough checkup and antihypertensive medication prescription. Diet alone should not be recommended by the nurse. 4. This is not the normal range for an older person's BP; the diastolic should be less than 80 mm Hg. TEST-TAKING HINT: Remember, the question asks which action should be implemented first. Therefore, more than one answer is appropriate, but the first to be implemented should be the one that directly affects the 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 and a BP of 170/100. 2. The client diagnosed with DVT and reporting chest pain. 3. The client diagnosed with pneumonia and a pulse oximeter reading of 98%. 4. The client diagnosed with ulcerative colitis and nonbloody diarrhea.

Answer: 2 1. This BP is elevated, but it is not life-threatening. 2. The chest pain could be a pulmonary embolus secondary to DVT and requires immediate intervention by the nurse. 3. A pulse oximeter reading of greater than 93% is within normal limits. 4. Nonbloody diarrhea is an expected clinical manifestation of ulcerative colitis and would not require immediate intervention by the nurse. TEST-TAKING HINT: The nurse should assess the client with abnormal assessment data or a life-threatening condition first when determining which client is a priority.

The RN and a UAP are bathing a bedfast client. Which action by the UAP warrants immediate intervention? 1. The UAP closes the door and cubicle curtain before undressing the client. 2. The UAP begins to massage and rub lotion into the client's calf. 3. The UAP tests the temperature of the water with the wrist before starting. 4. The UAP collects all the linens and supplies and brings them to the room.

Answer: 2 1. This protects the client's privacy. 2. The UAP could dislodge a blood clot in the leg when massaging the calf. The UAP can apply lotion gently, being sure not to massage the leg. 3. Testing the temperature of the water prevents scalding the client with water that is too hot or making the client uncomfortable with water that is too cold. 4. Collecting supplies needed before beginning the bath is using time wisely and avoids interrupting the bath to go and get items needed. TEST-TAKING HINT: This is an "except" question, so all options except one will be actions that should be encouraged. The test taker should not jump to the first option and choose it as the correct answer.

The client is diagnosed with an AAA. 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."

Answer: 2 1. This statement would not make the nurse suspect an AAA. 2. Only about two-fifths of clients diagnosed with AAA have symptoms; the remainder are asymptomatic. 3. Periodic episodes of constipation and diarrhea may indicate colon cancer but do not support a diagnosis of AAA. 4. Belching does not support a diagnosis of AAA, but it could possibly indicate gastroesophageal reflux or a hiatal hernia. TEST-TAKING HINT: The test taker must remember that not all disease processes or conditions have clinical manifestations. The test taker should attempt to determine what disease processes the other answer options are describing.

The client diagnosed with a DVT is placed on a medical unit. Which nursing interventions should be implemented? Select all that apply. 1. Place sequential compression devices on both legs. 2. Instruct the client to stay in bed and not ambulate. 3. Encourage fluids and a diet high in roughage. 4. Monitor IV site every 4 hours and prn. 5. Assess Homans' sign every 24 hours.

Answer: 2, 3, 4 1. Sequential compression devices provide gentle compression of the legs to prevent DVT, but they are not used to treat DVT because the compressions could cause the clot to break loose. 2. Clients should be on bedrest for 5 to 7 days after diagnosis to allow time for the clot to adhere to the vein wall, thereby preventing embolization. 3. Bedrest and limited activity predispose the client to constipation. Fluids and diets high in fiber will help prevent constipation. Fluids will also help provide adequate fluid volume in the vasculature. 4. The client will be administered a heparin IV drip, which should be monitored. 5. Homans' sign is assessed to determine if a DVT is present. This client has already been diagnosed with a DVT. Manipulating the leg to determine the presence of Homans' sign could dislodge the clot. TEST-TAKING HINT: Two of the answer options are used to determine if a DVT is present or to prevent one. The test taker should not become confused about treatment and prevention or early diagnosis.

The nurse is caring for a client receiving heparin therapy intravenously. Which assessment data would indicate to the nurse the client is developing heparin-induced thrombocytopenia (HIT)? Select all that apply. 1. The client has spontaneous bleeding from around the IV site. 2. The client reports chest pain on inspiration and has become restless. 3. The client's platelet count on admission was 420 (103) and now is 200 (103). 4. The client reports that the gums bleed when brushing the teeth. 5. The client has developed skin lesions at the IV site.

Answer: 2, 3, 5 1. Type 2 HIT is an immune-mediated disorder that typically occurs after exposure to heparin for 4 to 10 days and has life-threatening and limb-threatening thrombotic complications. The client clots rather than bleeds. Spontaneous bleeding is not associated with HIT. 2. HIT is not manifested by bleeding but by the development of clots, either deep venous or pulmonary, and sometimes arterially, which can cause a myocardial infarction. These are symptoms of a pulmonary embolus. 3. HIT is a decrease in baseline platelet count by 50% of baseline. 4. Bleeding is not associated with HIT. 5. Clinically, HIT may manifest itself as skin lesions at the site of heparin injections or chills, fever, dyspnea, or chest pain. TEST-TAKING HINT: The test taker must remember diseases and syndromes that do not match with the general picture of what is occurring. In HIT, the thrombocytopenia is not associated with bleeding but rather with clotting. This could eliminate options "1" and "4" because both are options indicating the client is bleeding.

The HCP prescribes an HMG-CoA reductase inhibitor (statin) medication to a client diagnosed with coronary artery disease. Which should the nurse teach the client about this medication? Select all that apply. 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. 5. Avoid drinking grapefruit juice.

Answer: 2, 5 1. Most statin medications can be taken with food or on an empty stomach. Lovastatin must be taken with food. 2. Most 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. 3. Cholesterol-reducing medications can cause serious liver problems, and if a client has muscle pain, it is an adverse effect that should be reported to the HCP. 4. The cholesterol level is checked every few months, not on a daily basis. 5. Grapefruit juice should be avoided during therapy because it increases the risk of toxicity. TEST-TAKING HINT: The test taker must be aware of adverbs such as "daily." Cholesterol is not monitored daily, so option "4" can be eliminated. There are only a few medications taken on an empty stomach; most medications can and should be administered with food to help prevent gastric irritation.

Which assessment data would cause the nurse to suspect the client has atherosclerosis? 1. Change in bowel movements. 2. Reports of a headache. 3. Intermittent claudication. 4. Venous stasis ulcers.

Answer: 3 1. A change in bowel movements may indicate cancer but not atherosclerosis. 2. A headache is not a clinical manifestation of atherosclerosis. 3. Intermittent claudication is a clinical manifestation of generalized atherosclerosis and is a marker of atherosclerosis. 4. Atherosclerosis indicates arterial involvement, not venous involvement. TEST-TAKING HINT: Knowledge of medical terminology—in this case, knowing that "atherosclerosis" refers to arteries—would allow the test taker to rule out all of the answer options except option "3," even if the test taker does not know what "intermittent claudication" means.

Which client would be most likely to develop an AAA? 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.

Answer: 3 1. AAAs affect males four to five times more often than females. 2. AAAs affect males four to five times more often than females. 3. The most common cause of AAA is atherosclerosis (which is the cause of peripheral vascular disease); it occurs in males four to five times more often than in females and primarily in whites. 4. AAAs occur most often in older males, and there is no genetic predisposition. TEST-TAKING HINT: If the test taker knew that AAA and peripheral vascular disease both occur with atherosclerosis, it might possibly lead to the selection of option "3" as the correct answer.

Which medication should the nurse expect the HCP to order for a client diagnosed with peripheral arterial disease? 1. An anticoagulant medication. 2. An antihypertensive medication. 3. An antiplatelet medication. 4. A muscle relaxant.

Answer: 3 1. Anticoagulant medication is prescribed for venous problems, such as DVT. 2. Peripheral arterial disease is caused by atherosclerosis, which may cause hypertension as well, but antihypertensive medications are not prescribed for peripheral arterial disease. 3. Antiplatelet medications, such as aspirin or clopidogrel (Plavix), inhibit platelet aggregations in the arterial blood. 4. A muscle relaxant will not help the leg pain because the origin of the pain is decreased oxygen to the muscle. TEST-TAKING HINT: The test taker should apply the knowledge learned in anatomy and physiology class. Platelets are part of the arterial blood; therefore, this would be an excellent selection if the test taker did not have any idea about the answer.

The client is being admitted with warfarin 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).

Answer: 3 1. BUN laboratory tests are measurements of renal functioning. 2. Bilirubin is a liver function test. 3. PT/INR is a test to monitor warfarin (Coumadin), an anticoagulant, action in the body. 4. PTT levels monitor heparin activity. TEST-TAKING HINT: The test taker should devise some sort of memory-jogging mnemonic or aid to remember which laboratory test monitors for which condition. Try "PT boats go to war," to recall that PT monitors warfarin.

The HCP prescribes an angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with essential (or primary) 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 BP by relaxing vascular smooth muscle.

Answer: 3 1. Beta-adrenergic blocking agents, not ACE inhibitors, prevent the beta receptor stimulation in the heart, which decreases heart rate and cardiac output. 2. Alpha-adrenergic blockers, not ACE inhibitors, block alpha receptors in the vascular smooth muscle, which decreases vasomotor tone and vasoconstriction. 3. ACE inhibitors prevent the conversion of angiotensin I to angiotensin II, and this, in turn, prevents vasoconstriction and sodium and water retention. 4. Vasodilators, not ACE inhibitors, reduce BP by relaxing vascular smooth muscle, especially in the arterioles. TEST-TAKING HINT: The test taker needs to understand how the major classifications of medications work to answer this question.

The nurse identifies the concept of clotting for a client diagnosed with a DVT. Which clinical manifestations support the diagnosis? 1. Brown-purple discoloration on the calf. 2. Bright red skin on the lower legs. 3. Swelling in the calf, warmth, and tenderness. 4. Pain after walking for short distances that resolve with rest.

Answer: 3 1. Brown-purple discoloration on the calf indicates a venous insufficiency issue, not a clot. 2. Bright red skin on the lower legs indicates an arterial issue, not a clot. 3. A clot disrupts the blood flow; swelling and warmth, along with pain, indicate a potential blood clot. 4. Pain after walking for short distances that resolves with rest indicates peripheral arterial disease, usually caused by the narrowing of the arteries as a result of atherosclerosis. TEST-TAKING HINT: The test taker should apply pathophysiology knowledge to answer this question. Venous blood is returning to the heart to pick up oxygen from the lungs and be redistributed to the body, making it a bright red color; oxygen in the blood makes the blood bright red. This could eliminate both options "1" and "2."

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.

Answer: 3 1. External heating devices are avoided to reduce the risk of burns. 2. Elastic support hose reduce the circulation to the skin and are avoided. 3. Walking promotes the development of collateral circulation to ischemic tissue and slows the process of atherosclerosis. 4. The feet must be checked daily, not weekly. TEST-TAKING HINT: The test taker must note the noun "week" in option "4," which could eliminate this distracter as a possible answer.

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.

Answer: 3 1. Fried foods are high in fat and cholesterol. 2. White bread is not high in fiber; wheat bread should be recommended because it is high in fiber. Whole milk is high in fat; skim milk should be used. 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. 4. Hamburger meat is high in fat, French fries are usually cooked in oil (which is high in fat), and carbonated beverages are high in calories. TEST-TAKING HINT: The nurse must be aware of special diets, and a low-fat, low-cholesterol diet is often prescribed for clients diagnosed with atherosclerosis. Remember, baked, broiled, and grilled meats are lower in fat and cholesterol than fried meats.

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.

Answer: 3 1. Glucose does not combine with carbon monoxide. 2. Vasoconstriction is not a risk factor for developing atherosclerosis. 3. This is the scientific rationale for why diabetes mellitus is a modifiable risk factor for atherosclerosis. 4. When glucose combines with the hemoglobin in a laboratory test called glycosylated hemoglobin, the result can determine the client's average glucose level over the past 3 months. TEST-TAKING HINT: The nurse must understand the reason "why," or the scientific rationale, for teaching in addition to nursing interventions. This is critical thinking.

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."

Answer: 3 1. Kidney disease leads to secondary hypertension; secondary hypertension is elevated BP resulting from an identifiable underlying process. 2. A high-salt, high-fat, high-cholesterol diet is a risk factor for essential hypertension, but it is not the only cause; therefore, this would be an incorrect answer. 3. There is no known cause for essential hypertension, but many factors—both modifiable (obesity, smoking, diet) and nonmodifiable (family history, age, sex)—are risk factors for essential hypertension. 4. This is a therapeutic reply that is inappropriate because the client needs facts. TEST-TAKING HINT: When clients request information, the exchange should not address emotions. Just facts should be given. Therefore, option "4" can be eliminated as a correct answer.

The nurse has just received the morning shift report. Which client would the nurse assess first? 1. The client diagnosed with a venous stasis ulcer reporting pain. 2. The client diagnosed with varicose veins reporting dull, aching muscle cramps. 3. The client diagnosed with peripheral arterial disease unable to move the foot. 4. The client diagnosed with DVT and a positive Homans' sign.

Answer: 3 1. The client diagnosed with a venous stasis ulcer should have pain, so this would be expected. 2. Dull, aching muscle cramps are expected with varicose veins. 3. The inability to move the foot means that a severe neurovascular compromise has occurred, and the nurse should assess this client first. 4. A positive Homans' sign is expected in a client diagnosed with DVT. TEST-TAKING HINT: The nurse should first assess the client experiencing an abnormal, unexpected, or life-threatening complication of the disease process. Do not automatically select the client diagnosed with pain; pain in many instances is not life-threatening or unexpected.

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 BP four 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.

Answer: 3 1. The client should occasionally monitor his BP but not four times a day. 2. Antihypertensive medications do not have established therapeutic blood levels. 3. Antihypertensive medications can cause a drop in the BP 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. 4. Blood glucose meters measure glucose levels, which is not what should be monitored for hypertension. TEST-TAKING HINT: The test taker should be aware of commonly administered medications and which instructions apply. This will allow the test taker to make decisions as to the appropriate nursing actions to implement.

The home health nurse is admitting a client diagnosed with a DVT. Which action by the client warrants immediate intervention by the nurse? 1. The client takes a stool softener every day at dinnertime. 2. The client is wearing a Medic Alert bracelet. 3. The client takes vitamin E over-the-counter medication. 4. The client has purchased a new recliner that will elevate the legs.

Answer: 3 1. There is nothing that contraindicates the use of a stool softener, and the use of one may be recommended if the client is prone to constipation and hard stool that could cause some bleeding from hemorrhoids. 2. A Medic Alert bracelet notifies any emergency HCP of the client's condition and medications. 3. Vitamin E can affect the action of warfarin. The nurse should explain to the client that these and other medications could potentiate the action of warfarin. 4. This will be recommended for the client if the footrest does not restrict blood flow in the calves. TEST-TAKING HINT: The test taker can eliminate option "1" by realizing that a stool softener would not cause a problem and could help with an unrelated problem. Medic Alert bracelets are frequently recommended for many clients diagnosed with certain diseases and conditions.

Which assessment data would warrant immediate intervention in the client diagnosed with peripheral arterial 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.

Answer: 3 1. These are normal pedal pulses and would not require any intervention. 2. Moving the toes is a good sign in a client diagnosed with peripheral arterial disease. 3. Numbness and tingling are paresthesias, which are a clinical manifestation of a severely decreased blood supply to the lower extremities. 4. Reddened extremities are expected secondary to increased blood supply when the legs are in the dependent position. TEST-TAKING HINT: "Warrants immediate intervention" indicates that the test taker must select the distracter that is abnormal, unexpected, or life-threatening for the client's disease process. Sometimes if the test taker flips the question and thinks which assessment data are normal for the disease process, it is easier to identify the correct answer.

The client receiving low molecular weight heparin (LMWH) subcutaneously to prevent DVT following hip replacement surgery reports to the nurse that there are small purple hemorrhagic areas on the right and left sides of the abdomen. Which action should the nurse implement? 1. Notify the HCP immediately. 2. Check the client's PTT level. 3. Explain this is a result of the medication. 4. Assess the client's vital signs.

Answer: 3 1. This occurs from the administration of the LMWH and is not a reason to notify the HCP. 2. A therapeutic range will not be achieved with LMWH, and PTT levels are usually not done. 3. This is not hemorrhaging, and the client should be reassured that this is a side effect of the medication. 4. Assessing the vital signs will not provide any pertinent information to help answer the client's question. TEST-TAKING HINT: Before selecting "Notify the HCP," the test taker should ask, "What will the HCP do with this information? What can the HCP order or do to help the purple hemorrhaged areas?" This would cause the test taker to eliminate option "1" as a possible answer.

The nurse is teaching a class on venous insufficiency. The nurse would identify which condition as the most serious complication of chronic venous insufficiency? 1. Arterial thrombosis. 2. Deep vein thrombosis. 3. Venous ulcerations. 4. Varicose veins.

Answer: 3 1. Venous insufficiency is a venous problem, not an arterial problem. 2. DVT is not a complication of chronic venous insufficiency, but it may be a cause. 3. Venous ulcerations are the most serious complication of chronic venous insufficiency. It is very difficult for these ulcerations to heal, and often clients must be seen in wound care clinics for treatment. 4. Varicose veins may lead to chronic venous insufficiency, but they are not a complication. TEST-TAKING HINT: The test taker must use knowledge of anatomy, which would eliminate option "1" because "venous" and "arterial" refer to different parts of the vascular system. The test taker must key in on the most serious complication to select the correct answer.

The nurse is discharging a client diagnosed with DVT from the hospital. Which discharge instructions should be provided to the client? Select all that apply. 1. Have the partial thromboplastin time (PTT) levels checked weekly until the therapeutic range is achieved. 2. Staying at home is best, but if traveling, airplanes are better than automobiles. 3. Avoid green, leafy vegetables, such as spinach and collard greens. 4. Wear knee stockings with an elastic band around the top. 5. Notify the HCP of red or brown urine or emesis.

Answer: 3, 5 1. The client will be taking an oral anticoagulant, warfarin (Coumadin). Prothrombin time (PT/INR) levels, not PTT, are monitored when this medication is taken. The client should be in the therapeutic range before discharge. The HCP will determine how often to monitor the levels, usually in 2 to 3 weeks and then at 3- to 6-month intervals. 2. The client is not restricted to the home. The client should not take part in any activity that does not allow frequent active and passive leg exercises. In an airplane, the client should be instructed to drink plenty of fluids, move the legs up and down, and flex the muscles. If in an automobile, the client should stop to take frequent breaks to walk around. 3. Green, leafy vegetables contain vitamin K, which is the antidote for warfarin. These foods will interfere with the action of warfarin. Red or brown urine may indicate bleeding. 4. The client should be instructed to wear stockings that do not constrict any area of the leg. 5. Red or brown urine, emesis, or sputum may indicate bleeding. TEST-TAKING HINT: The test taker must know laboratory data for specific medications. The INR and PT are monitored for oral anticoagulants. Remember: "PT boats go to war" (warfarin). PTT monitors heparin ("tt" is like an H for heparin).

The RN and an unlicensed assistive personnel (UAP) are caring for a 64-year-old client 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.

Answer: 4 1. A continuous passive motion machine is used for a client with a total knee replacement, not for this type of surgery. 2. The client will be on bedrest at 4 hours after the surgery. Remember, the client had bilateral surgery on the legs. 3. There is nothing in the stem that would indicate the client could not self-feed. The nurse should encourage independence as much as possible. 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. TEST-TAKING HINT: A concept that is applicable to surgery is decreasing edema, and extremity surgeries usually include elevating the affected extremity. The test taker must apply basic concepts when answering questions.

The client diagnosed with a DVT is prescribed heparin via continuous infusion. The client's laboratory data are listed in the table below. Based on the laboratory results, which intervention should the nurse implement? - PT: 12.2 - PTT: 48 - INR: 1 1. Request a change of medication to a subcutaneous anticoagulant. 2. Administer vitamin K IM. 3. Have the dietary department remove all green, leafy vegetables from the trays. 4. Administer the IV as ordered.

Answer: 4 1. The client is in the therapeutic range for intravenous heparin; the nurse has no reason to ask for a change of medication. 2. Heparin is administered based on the activated PTT results; phytonadione (Aqua-Mephyton or vitamin K) is the antidote for warfarin (Coumadin). 3. Limiting green, leafy vegetables applies to warfarin, not heparin, and all green, leafy vegetables are not prohibited. The client should consume a consistent amount of green, leafy vegetables in order for the INR levels to maintain a therapeutic range. 4. The client is in the therapeutic range for intravenous heparin; the nurse should administer the heparin as ordered. TEST-TAKING HINT: The test taker should be aware of therapeutic levels as they apply to commonly administered medications. This will allow the test taker to make decisions as to the appropriate nursing actions to implement.

The client presents to the outpatient clinic reporting calf pain. The client reports returning from an airplane trip the previous day. Which should the nurse assess first? 1. The nurse should auscultate the lung fields and heart sounds. 2. The nurse should determine the length of the airplane trip. 3. The nurse should determine if the client has had chest pain. 4. The nurse should measure the calf and palpate the calf for warmth.

Answer: 4 1. Auscultation of heart and lung sounds is part of a full assessment, but the first action is to focus on the client's chief concern; the results of this assessment will guide the remainder of the nurse's actions. 2. The length of the trip is implicated in the client developing a blood clot because of the lower moisture content in the air being breathed and the lack of movement of the lower extremities during the flight; however, if the client has developed a clot, then that is the issue now. 3. If the client had experienced chest pain, that would have been the chief concern; the nurse needs to assess the client for a DVT. 4. Measuring the client's calf and assessing for warmth are part of a focused assessment for DVT, for which the flight placed the client at risk. TEST-TAKING HINT: The test taker should apply decision-making questions when determining which to do first. One such question is, Which option will give the nurse the most needed information the fastest? The nurse should acquire information that will eliminate or support the suspected diagnosis.

The client diagnosed with peripheral vascular disease is overweight, has smoked two 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.

Answer: 4 1. Being overweight is not a risk factor for atherosclerotic lesions, but it does indicate that the client does not eat a healthy diet or exercise as needed. 2. Lack of exercise is a risk factor, but it is not the strongest. 3. Although the stem did not explicitly identify diet, the nurse should assume that an obese client would not eat a low-fat, low-cholesterol diet. 4. Although tobacco use has declined in the United States, tobacco use is still the strongest factor in the development of atherosclerotic lesions. Nicotine decreases blood flow to the extremities and increases heart rate and BP. It also increases the risk of clot formation by increasing the aggregation of platelets. TEST-TAKING HINT: The test taker should look at the answer options closely to determine if any are similar. This will help eliminate two options—"1" and "3"—as possible answers. An unhealthy diet will cause the client to be overweight.

The nurse is planning care for a client diagnosed with peripheral arterial 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.

Answer: 4 1. Isometric exercises are "pumping iron" or body-building exercises. Isotonic exercises are what the nurse teaches the client to perform. 2. A stair stepper places considerable requirements for lower body strength on the client. The client diagnosed with peripheral arterial disease may not have the ability to use this machine. 3. Warm-up exercises are needed to prevent injury to the client. 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. TEST-TAKING HINT: The test taker could eliminate option "1" if aware of the definition of isometric; the test taker must be knowledgeable regarding medical terminology.

The client is employed in a job that requires extensive standing. Which intervention should the nurse include when discussing how to prevent varicose veins? 1. Wear low-heeled, comfortable shoes. 2. Wear clean white cotton socks. 3. Move the legs back and forth often. 4. Wear graduated compression hose.

Answer: 4 1. Low-heeled, comfortable shoes should be recommended to help decrease foot pain, but they will not help prevent varicose veins. 2. Wearing clean white socks will help prevent irritation to the feet, but they will not help prevent varicose veins. 3. Moving the legs back and forth often may help prevent DVT, but it will not prevent varicose veins. 4. Graduated compression hose help decrease edema and increase the circulation back to the heart; this helps prevent varicose veins. TEST-TAKING HINT: Options "1" and "2" could be eliminated as possible answers if the test taker knows that the varicose veins are in the leg because options "1" and "2" are addressing the feet.

The male client is diagnosed with Guillain-Barré (GB) syndrome and is in the intensive care unit on a ventilator. Which cardiovascular rationale explains implementing passive range-of-motion (ROM) exercises? 1. Passive ROM exercises will prevent contractures from developing. 2. The client will feel better if he is able to exercise and stretch his muscles. 3. ROM exercises will help alleviate the pain associated with GB syndrome. 4. They help to prevent DVTs by the movement of the blood through the veins.

Answer: 4 1. Passive ROM exercises are recommended to prevent contracture formation and muscle atrophy, but this is a musculoskeletal complication, not a cardiovascular one. 2. If the client is on a ventilator, then the paralysis associated with GB syndrome has moved up the spinal column to include the muscles of respiration. Passive ROM exercises are done by the staff; the client will not be able to do active ROM. 3. ROM exercises will not alleviate the pain of GB syndrome. 4. One reason for performing ROM exercises is to assist the blood vessels in the return of blood to the heart, preventing DVT. TEST-TAKING HINT: The question is asking for a cardiovascular reason for ROM exercises. Options "1," "2," and "3" do not have any cardiovascular component. Only option "4" discusses veins and blood.

Which assessment data would the nurse expect to find in the client diagnosed with chronic venous insufficiency? 1. Decreased pedal pulses. 2. Cool skin temperature. 3. Intermittent claudication. 4. Brown discolored skin.

Answer: 4 1. Pedal pulses are normal in venous insufficiency, but pulses are decreased or absent in arterial insufficiency. 2. The skin is warm in venous insufficiency; the skin is cool in arterial insufficiency. 3. Intermittent claudication, pain that occurs when walking, is a symptom of arterial insufficiency. 4. Chronic venous insufficiency leads to chronic edema that, in turn, causes a brownish pigmentation to the skin. TEST-TAKING HINT: The test taker could apply anatomical concepts to eliminate both options "1" and "2" because it is the arteries that have pulses and control the temperature of the skin.

The client prescribed rivaroxaban is reporting dark, tarry stool. Which should the nurse implement first? 1. Notify the health-care provider. 2. Ask the client to provide a stool sample. 3. Ask the client when the rivaroxaban was last taken. 4. Assess the client for ecchymotic areas and bleeding.

Answer: 4 1. The nurse must complete the assessment before notifying the HCP. 2. This can be done, but most clients cannot provide a stool sample immediately. 3. The timing is not important at this time; the client has been taking the rivaroxaban (Xarelto), an anticoagulant. 4. Ecchymotic areas (bruising) indicate bleeding; the nurse should determine the extent of the client's bleeding before notifying the HCP. TEST-TAKING HINT: When answering a question and the test taker wishes to choose "notify the HCP," the test taker should read all the options carefully; if any option has needed information to report to the HCP, then that option comes before notifying the HCP.

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."

Answer: 4 1. The nurse should assume the client is a layperson and should not explain disease processes using medical terminology. 2. This is passing the buck; the nurse should have the knowledge to answer this question. 3. Atherosclerosis involves the arteries, not the veins. 4. This response explains in plain terms why the client's legs hurt from atherosclerosis. TEST-TAKING HINT: If the test taker knows medical terminology, option "3" could be eliminated because athero- means "arteries," not veins. The test taker should be very cautious when choosing an option that asks the HCP to answer questions that nurses should be able to answer.

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 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.

Answer: 4 1. The potassium level is not affected by an alpha-adrenergic blocker. 2. Alpha-adrenergic blockers, on rare occasions, can cause sexual problems. Noncompliance with taking prescribed medications can occur in male clients who experience impotence. The noncompliance should be reported to the HCP immediately so that the medication can be changed. Impotence, however, is not an expected side effect. 3. The medication can be taken on an empty or a full stomach, depending on whether the client becomes nauseated after taking the medication. 4. Orthostatic hypotension may occur when the BP is decreasing and may lead to dizziness and light-headedness, so the client should change position slowly. TEST-TAKING HINT: The test taker should understand the side effects of medications. The test taker not knowing the answer may realize that hypertension is being treated and that hypotension is the opposite of hypertension and might be a complication of treating hypertension. Only option "4" refers to hypotension, providing advice on how to avoid orthostatic hypotension.

The client diagnosed with peripheral arterial disease is 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 4 hours.

Answer: 4 1. The right leg should be elevated to decrease edema, not flat or hanging off the side of the bed (dependent). 2. The left leg could have a sequential compression device to prevent DVT, but it should not be on the leg with an operative incision site. 3. The client is 1 day postoperative, and the pedal pulses must be assessed more than once every 8 or 12 hours. 4. The leg dressing needs to be assessed for hemorrhaging or findings of infection. TEST-TAKING HINT: The test taker must be observant of time ("1 day postoperative"), and doing an intervention every "shift" should cause the test taker to eliminate this distracter. The test taker must know terms used to describe positioning, such as dependent, prone, and supine.

The client is at risk for 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 BP to less than 140/90. 2. Instruct the client to exercise 30 minutes a day three times a week. 3. Demonstrate how to take the BP using a battery-operated cuff. 4. Inform the client to limit fat intake and which foods have a higher fat content.

Answer: 4 1. The usual guideline is to keep the BP to less than 160/100; 140/90 is the low number to diagnose hypertension. 2. This will improve cardiovascular fitness but will not directly cause an increase in atherosclerosis. 3. This will allow the client to monitor the BP but does not reduce the risk of an MI. 4. Atherosclerosis is caused by plaque buildup in the arteries. Plaque is primarily caused by fat in the diet compounded by clotting mechanisms. TEST-TAKING HINT: The test taker must be aware of the recommended treatment for the prevention of the problems associated with disease processes in order to teach the client about the disease.

The HCP ordered a femoral angiogram for the client diagnosed with peripheral arterial disease. Which interventions should the nurse implement? Select all that apply. 1. Explain that this procedure will be done at the bedside. 2. Discuss bedrest orders and bathroom privileges with the client. 3. Inform the client that no intravenous access will be needed. 4. Inform the client that fluids will be increased after the procedure. 5. Teach the client that a local anesthetic will be used during the procedure.

Answer: 4, 5 1. This procedure will be done in a catheterization laboratory or special room, not at the bedside, because machines are used to visualize the extent of the arterial occlusion. 2. The client will have to keep the leg straight for at least 6 hours after the procedure to prevent bleeding from the femoral artery. 3. An intravenous contrast medium is injected, and vessels are visualized using fluoroscopy and x-rays. 4. Fluids will help flush the contrast dye out of the body and help prevent kidney damage. 5. A local anesthetic will be used to numb the skin at the insertion site. TEST-TAKING HINT: The test taker must be knowledgeable of diagnostic tests. If not, the test taker could dissect the word "angiogram"; angio- means "vessel," which could help eliminate option "3" as a possible answer because some type of dye would have to be used to visualize a vessel. Adjectives should be noted—anything done in the femoral artery would require pressure at the site to prevent bleeding—this information could help the test taker to eliminate option "2" as a possible answer. Very few diagnostic tests are done at the bedside.