Unit 4.00

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A nurse is reinforcing discharge teaching with a client who has a new permanent pacemaker. Which of the following information should the nurse include in the teaching?

"Avoid lifting both arms above your head when dressing."

A nurse is reinforcing teaching about lifestyle changes with a client who had a myocardial infarction and has a new prescription for a beta blocker. Which of the following client statements indicates an understanding of the teaching?

"Before taking my medication, I will check my blood pressure and radial pulse rate."

Before discharge, which instruction should a nurse give to a client receiving digoxin?

"Call the physician if your heart rate is above 90 beats/minute."

A nurse is teaching a client who will soon be discharged with a prescription for warfarin (Coumadin). Which statement should the nurse include in discharge teaching? -"This drug will dissolve any clots you may still have." -"Don't take aspirin while you're taking warfarin." -"If you miss a dose, double the next dose." -"Eat more yogurt and broccoli."

"Don't take aspirin while you're taking warfarin." Explanation: Because aspirin decreases platelet aggregation and interferes with clotting, concomitant use of aspirin with warfarin, an anticoagulant, may lead to excessive anticoagulant effects — and bleeding. Warfarin therapy is most effective with consistent dietary intake of vitamin K. Increase intake of foods rich in vitamin K, such as broccoli, could change the client's warfarin dose requirements. Although warfarin interrupts the normal clotting cycle, it doesn't dissolve clots that have already formed. The client should take warfarin exactly as ordered to maintain the desired level of anticoagulation. Doubling a dose could cause bleeding. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Deep Vein Thrombosis, p. 848.

The nurse is addressing exercise and physical activity during discharge education with a client diagnosed with heart failure. What should the nurse teach this client about exercise?

"Eventually aim to work up to 30 minutes of exercise each day."

The client is diagnosed with an abdominal aortic aneurysm. Which statement would the nurse expect the client to make during the admission assessment?

"I don't have any abdominal pain or any type of problems."

A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures? a) "I stopped smoking and use only chewing tobacco." b) "I like to soak my feet in the hot tub every day." c) "I walk only to the mailbox in my bare feet." d) "I have my wife look at the soles of my feet each day."

"I have my wife look at the soles of my feet each day." A client with peripheral vascular disease should examine his feet daily for redness, dryness, or cuts. If a client isn't able to do this examination on his own, then a caregiver or family member should help him. A client with peripheral vascular disease should avoid hot tubs because decreased sensation in the feet may make him unable to tell if the water is too hot. The client should always wear shoes or slippers on his feet when he is out of bed to help minimize trauma to the feet. Any type of nicotine, whether it's from cigarettes or smokeless tobacco, can cause vasoconstriction and further decrease blood supply to the extremities.

A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures? "I have my wife look at the soles of my feet each day." "I walk only to the mailbox in my bare feet." "I stopped smoking and use only chewing tobacco." "I like to soak my feet in the hot tub every day."

"I have my wife look at the soles of my feet each day." Explanation: A client with peripheral vascular disease should examine his feet daily for redness, dryness, or cuts. If a client isn't able to do this examination on his own, then a caregiver or family member should help him. A client with peripheral vascular disease should avoid hot tubs because decreased sensation in the feet may make him unable to tell if the water is too hot. The client should always wear shoes or slippers on his feet when he is out of bed to help minimize trauma to the feet. Any type of nicotine, whether it's from cigarettes or smokeless tobacco, can cause vasoconstriction and further decrease blood supply to the extremities.

A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement?

"I sleep on three pillows each night." Orthopnea is a classic sign of left-sided heart failure. The client commonly sleeps on several pillows at night to help facilitate breathing. Swollen feet, ascites, and anorexia are signs of right-sided heart failure.

The nurse completes discharge teaching for a patient following a femoral-to-popliteal bypass graft. What response by the patient would indicate teaching was effective? a) "It will important for me to sit at the kitchen table to promote better breathing." b) "I can now stop taking my Lipitor because my leg is fixed." c) "I can stop the exercises that were started in the hospital once I return home." d) "I will call if I develop any coldness, numbness, tingling, or pain in the surgical leg."

"I will call if I develop any coldness, numbness, tingling, or pain in the surgical leg." The nurse ensures that the patient has the knowledge and ability to assess for any postoperative complications such as infection, occlusion of the artery or graft, and decreased blood flow. Coldness, numbness, tingling, and pain are signs of peripheral arterial occlusion, and immediate intervention is required.

A client with heart failure is placed on a low-sodium diet. Which statement by the client indicates that the nurse's nutritional teaching plan has been effective?

"I will have a baked potato with broiled chicken for dinner."

A community health nurse teaches a group of seniors about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which of the following statements? a) "I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels." b) "Since my family is from Italy, I have a higher risk of developing peripheral arterial disease." c) "I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." d) "The older I get the higher my risk for peripheral arterial disease gets."

"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." The use of tobacco products may be one of the most important risk factors in the development of atherosclerotic lesions. Nicotine in tobacco decreases blood flow to the extremities and increases heart rate and blood pressure by stimulating the sympathetic nervous system. This causes vasoconstriction, thereby decreasing arterial blood flow. It also increases the risk of clot formation by increasing the aggregation of platelets.

A community health nurse teaches a group of older adults about modifiable risk factors that contribute to the development of peripheral arterial disease (PAD). The nurse knows that the teaching was effective based on which statement? -"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." -"The older I get the higher my risk for peripheral arterial disease gets." -"Because my family is from Italy, I have a higher risk of developing peripheral arterial disease." -"I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels."

"I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet." Explanation: The use of tobacco products may be one of the most important risk factors in the development of atherosclerotic lesions. Nicotine in tobacco decreases blood flow to the extremities and increases heart rate and blood pressure by stimulating the sympathetic nervous system. This causes vasoconstriction, thereby decreasing arterial blood flow. It also increases the risk of clot formation by increasing the aggregation of platelets. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Arteriosclerosis and Atherosclerosis, pp. 826-831.

The nurse is teaching a client with heart failure about digoxin. What statements by the client indicate the teaching is effective? Select all that apply.

"I will watch my urine output to be sure that the medication is not affecting my kidneys." "If I take my digoxin I should have limited episodes of shortness of breath."

A client with peripheral arterial disease asks the nurse about using a heating pad to warm the feet. The nurse's best response is which of the following? a) "It is better to soak your feet in hot water as long as the water temperature is below 110 degrees F." b) "A heating pad to your feet is a good idea because it increases the metabolic rate." c) "It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet." d) "A heating pad to your feet is fine as long as the temperature stays below 105 degrees F."

"It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet." It is safer to apply a heating pad to the abdomen, causing a reflex vasodilation in the extremities. Heat may be applied directly to ischemic extremities; however, the temperature of the heating source must not exceed body temperature. Excess heat may increase the metabolic rate of the extremities and increase the need for oxygen beyond that provided by the reduced arterial flow through the diseased artery.

A client with peripheral arterial disease asks the nurse about using a heating pad to warm the feet. The nurse's best response is which of the following? -"It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet." -"It is better to soak your feet in hot water as long as the water temperature is below 110 degrees F." -"A heating pad to your feet is a good idea because it increases the metabolic rate." -"A heating pad to your feet is fine as long as the temperature stays below 105 degrees F."

"It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet." Explanation: It is safer to apply a heating pad to the abdomen, causing a reflex vasodilation in the extremities. Heat may be applied directly to ischemic extremities; however, the temperature of the heating source must not exceed body temperature. Excess heat may increase the metabolic rate of the extremities and increase the need for oxygen beyond that provided by the reduced arterial flow through the diseased artery. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Arteriosclerosis and Atherosclerosis, p. 832.

A client has been diagnosed with systolic heart failure. What percentage will the nurse expect the patient's ejection fraction to be?

30%

A client complains of leg pain brought on by walking several blocks — a symptom that first arose several weeks earlier. The client's history includes diabetes mellitus and a two-pack-per-day cigarette habit for the past 42 years. The physician diagnoses intermittent claudication and orders pentoxifylline (Trental), 400 mg three times daily with meals. Which instruction concerning long-term care should the nurse provide? a) "See the physician if complications occur." b) "Reduce your level of exercise." c) "Practice meticulous foot care." d) "Consider cutting down on your smoking."

"Practice meticulous foot care." Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing. Therefore, meticulous foot care is essential. The nurse should teach the client to bathe his feet in warm water and dry them thoroughly, cut the toenails straight across, wear well-fitting shoes, and avoid taking medications without the approval of a physician. Because nicotine is a vasoconstrictor, this client should stop smoking, not just consider cutting down. Daily walking is beneficial to clients with intermittent claudication. To evaluate the effectiveness of the therapeutic regimen, this client should see the physician regularly, not just when complications occur.

A nurse is providing education about maintaining tissue integrity to a client with peripheral arterial disease. Which of the following statements by the client indicates a need for clarification? "I can use lamb's wool between my toes if necessary." "It is important to apply sunscreen to the top of my feet when wearing sandals." "Shoes made of synthetic material are best for my feet." "I should apply powder daily because my feet perspire."

"Shoes made of synthetic material are best for my feet."

A nurse is providing education about maintaining tissue integrity to a client with peripheral arterial disease. Which of the following statements by the client indicates a need for clarification? a) "Shoes made of synthetic material are best for my feet." b) "I should apply powder daily because my feet perspire." c) "I can use lamb's wool between my toes if necessary." d) "It is important to apply sunscreen to the top of my feet when wearing sandals."

"Shoes made of synthetic material are best for my feet." The client should wear leather shoes with an extra-depth toebox. Synthetic shoes do not allow air to circulate.

A nurse is providing education about maintaining tissue integrity to a client with peripheral arterial disease. Which of the following statements by the client indicates a need for clarification? -"I should apply powder daily because my feet perspire." -"It is important to apply sunscreen to the top of my feet when wearing sandals." -"I can use lamb's wool between my toes if necessary." -"Shoes made of synthetic material are best for my feet."

"Shoes made of synthetic material are best for my feet." Explanation: The client should wear leather shoes with an extra-depth toe box. Synthetic shoes do not allow air to circulate. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Peripheral Artery Disease, p. 834.

A patient admitted to the medical surgical unit with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are needed. Which response by the nurse is accurate? a) "Lovenox will dissolve the clot, and Coumadin will prevent any more clots from occurring." b) "Administration of two anticoagulants decreases the risk of recurrent venous thrombosis." c) "The Lovenox will work immediately, but the Coumadin takes several days to reach its full effect." d) "Because of the potential for a pulmonary embolism, it is important for you to have at least two anticoagulants."

"The Lovenox will work immediately, but the Coumadin takes several days to reach its full effect." Oral anticoagulants, such as warfarin, are monitored by the prothrombin time (PT) or the international normalized ratio (INR). Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (ie, when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0).

A client admitted to the medical-surgical unit with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are needed. Which response by the nurse is accurate? "Administration of two anticoagulants decreases the risk of recurrent venous thrombosis." "Enoxaparin will dissolve the clot, and warfarin will prevent any more clots from occurring." "Because of the potential for a pulmonary embolism, it is important for you to take at least two anticoagulants." "The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect."

"The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect."

A client admitted to the medical-surgical unit with a venous thromboembolism (VTE) is started on enoxaparin and warfarin. The client asks the nurse why two medications are needed. Which response by the nurse is accurate? -"The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect." -"Administration of two anticoagulants decreases the risk of recurrent venous thrombosis." -"Enoxaparin will dissolve the clot, and warfarin will prevent any more clots from occurring." -"Because of the potential for a pulmonary embolism, it is important for you to take at least two anticoagulants."

"The enoxaparin will work immediately, but the warfarin takes several days to achieve its full effect." Explanation: Oral anticoagulants such as warfarin are monitored by the prothrombin time (PT) or the international normalized ratio (INR). Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Deep Vein Thrombosis, pp. 846-848.

A nurse is preparing to perform a cardiovascular assessment on a client. The client asks, "Why do you need to use a penlight?" Which of the following responses should the nurse make?

"The penlight will allow me to look at the pulses in your neck."

The nurse is assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse include in the education of the patient during ambulation? "As soon as you feel pain, we will go back and elevate your legs." "Walk to the point of pain, rest until the pain subsides, then resume ambulation." "If you feel any discomfort, stop and we will use a wheelchair to take you back to your room." "If you feel pain during the walk, keep walking until the end of the hallway is reached."

"Walk to the point of pain, rest until the pain subsides, then resume ambulation."

The nurse is assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse include in the education of the patient during ambulation? -"If you feel pain during the walk, keep walking until the end of the hallway is reached." -"As soon as you feel pain, we will go back and elevate your legs." -"Walk to the point of pain, rest until the pain subsides, then resume ambulation." -"If you feel any discomfort, stop and we will use a wheelchair to take you back to your room."

"Walk to the point of pain, rest until the pain subsides, then resume ambulation." Explanation: The nurse instructs the patient to walk to the point of pain, rest until the pain subsides, and then resume walking so that endurance can be increased as collateral circulation develops. Pain can serve as a guide in determining the appropriate amount of exercise. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Arteriosclerosis and Atherosclerosis, p. 829.

The nurse explains to a patient that the primary cause of a varicose vein is: Venous occlusion. Venospasm. Phlebothrombosis. An incompetent venous valve.

An incompetent venous valve.

A client with peripheral arterial disease asks the nurse about using a heating pad to warm the feet. The nurse's best response is which of the following? "A heating pad to your feet is fine as long as the temperature stays below 105 degrees F." "It is better to soak your feet in hot water as long as the water temperature is below 110 degrees F." "A heating pad to your feet is a good idea because it increases the metabolic rate." "It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet."

"\"It is better to put the heating pad on your abdomen, which causes vasodilation and warmth to your feet."

The physician prescribed a Tegapore dressing to treat a venous ulcer. What should the nurse expect that the ankle-brachial index (ABI) will be if the circulatory status is adequate? -0.50 -0.35 -0.25 -0.10

0.50 After the circulatory status has been assessed and determined to be adequate for healing (ABI of more than 0.5) (Mosti, Iabichella, & Partsch, 2012), surgical dressings can be used to promote a moist environment. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Doppler Ultrasound Flow Studies, p. 822.

0.50Explanation:After the circulatory status has been assessed and determined to be adequate for healing (ABI of more than 0.5) (Mosti, Iabichella, & Partsch, 2012), surgical dressings can be used to promote a moist environment.

A nurse is assisting in the care of a client who is in hypovolemic shock. While waiting for a unit of blood, the nurse should plan to administer which of the following IV solutions?

0.9% sodium chloride

Which of these are expected findings of pulmonary edema? Select all 1.Tachypnea 2.Persistent cough 3.Increase urinary output 4.Thick yellow sputum 5.Orthopnea

1.Tachypnea- expected 2.Persistent cough-will be frothy pink and indicates pulm. edema 5.Orthopnea- Expected **3.Increase UOP- would be decreased 4.Thick yellow sputum- would be pink and frothy sputum

A nurse is preparing to transfuse 250 mL of packed red blood cells (RBCs) to a client over 4 hr. Available is a blood administration set that delivers 10 gtt/mL. The nurse should set the manual blood transfusion to deliver how many gtt/min?

10 gtt/min

A nurse is caring for a client in a clinic who asks the nurse why her provider prescribed 1 aspirin per day. which of the following is an appropriate response by the nurse? 1. "Aspirin reduces the formation of blood clots that could cause a heart attack." 2. "Aspirin relieves the pain due to MI." 3. "Aspirin dissolves clots that are forming in your coronary arteries." 4. "Aspirin relieves headaches that are caused by other medications."

1. "Aspirin reduces the formation of blood clots that could cause a heart attack."

ATI pulmonary embolism chapter 24 1. A nurse is caring for several clients. Which of the following clients are at risk for having a pulmonary embolism? (Select all that apply.) A. A client who has a BMI of 30 B. A female client who is postmenopausal C. A client who has a fractured femur D. A client who is a marathon runner E. A client who has chronic atrial fibrillation

1. A. CORRECT: A client who has a BMI of 30 is considered obese and is at increased risk for a blood clot. B. INCORRECT: A woman who is postmenopausal has decreased estrogen levels and is not at risk for developing a pulmonary embolism. C. CORRECT: A fractured bone, particularly in a long bone such as the femur, increases the risk of fat emboli. D. INCORRECT: A client who is a marathon runner increases the blood flow and circulation of his body, which decreases the risk for developing a pulmonary embolism. E. CORRECT: A client who has turbulent blood flow in the heart, such as with atrial defibrillation, is also at increased risk of a blood clot.

Chapter 41 anemias 1. A nurse is planning care for a client who has a Hgb of 7.5 and a Hct of 21.5. Which of the following should the nurse include in the plan of care? (Select all that apply.) A. Provide assistance with ambulation. B. Monitor oxygen saturation. C. Weigh the client weekly. D. Obtain stool specimen for occult blood. E. Schedule daily rest periods.

1. A. CORRECT: A client who has anemia may experience dizziness and should be assisted when ambulating to prevent a fall. B. CORRECT: Oxygen saturation should be monitored in a client who has anemia due to the decreased oxygen-carrying capacity of the blood. C. INCORRECT: The client should be weighed daily. D. CORRECT: Stool testing is performed to identify a possible cause of anemia due to gastrointestinal bleeding. E. CORRECT: A client who has anemia may experience fatigue, and rest periods should be planned to conserve energy.

ATI chapter 42 coagulation disorders 1. A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following indicates that the client's clotting factors are becoming depleted? (Select all that apply.) A. Platelets 100,000/mm³ B. Fibrinogen levels 97 mg/dL C. Fibrin degradation products 4.3 mcg/mL D. D-dimer 179 ng/mL E. Sedimentation rate 38 mm/hr

1. A. CORRECT: In DIC, platelet levels are decreased, causing clotting factors to become depleted. Clotting times are increased, which raises the risk for fatal hemorrhage. B. CORRECT: In DIC, fibrinogen levels are decreased, causing clotting factors to become depleted. Clotting times are increased, which raises the risk for fatal hemorrhage. C. INCORRECT: Fibrin degradation products are increased when DIC occurs. D. INCORRECT: A D-dimer level is increased when DIC occurs. E. INCORRECT: The sedimentation rate is increased, but it is not an indicator of DIC.

1. A nurse in a clinic is caring for a client who has suspected anemia. The nurse should anticipate a prescription from the provider for which of the following tests? A. INR B. Platelet count C. WBC count D. Hgb

1. A. INCORRECT: An INR test identifies the effectiveness of warfarin therapy. B. INCORRECT: A platelet count identifies an alteration in immune response. C. INCORRECT: A WBC count identifies the presence of an infection. D. CORRECT: An Hgb test is prescribed to confirm a diagnosis of anemia.

1. A nurse is performing a physical assessment of a client who has chronic peripheral arterial disease (PAD). Which of the following is an expected finding? A. Edema around the client's ankles and feet B. Ulceration around the client's medial malleoli C. Scaling eczema of the client's lower legs with stasis dermatitis D. Pallor on elevation of the client's limbs and rubor when his limbs are dependent

1. A. INCORRECT: Edema around the ankles and feet is an expected finding in a client who has venous stasis. B. INCORRECT: Ulceration around the medial malleoli is an expected finding in a client who has venous stasis. C. INCORRECT: Scaling eczema of the lower legs with stasis dermatitis is an expected finding in a client who has venous stasis. D. CORRECT: In a client who has chronic PAD, pallor is seen in the extremities when the limbs are elevated, and rubor occurs when they are lowered.

ATI chapter 40 1. A nurse should remain with a client during the first 15 min of a blood transfusion to A. verify the blood is being transfused. B. assess for an adverse reaction. C. explain the procedure to the client. D. obtain blood specimens.

1. A. INCORRECT: Verifying the blood being transfused occurs prior to blood administration. B. CORRECT: Assessment of the client during the first 15 min of the transfusion is important because this is when most blood reactions occur. C. INCORRECT: Explanation of the procedure should be done prior to blood administration. D. INCORRECT: Blood specimens are obtained only in the event of a blood reaction.

You are caring for a PT receiving hemodynamic monitoring and has the following readings: PAS 34, PAD 21, PAWP 16, CVP 12. which is the PT at risk for? Select All 1. Heart failure 2. Cor pulmonale 3. Hypovolemic shock 4. Pulmonary hypertension 5. Peripheral edema

1. Heart failure-r/t left ventricular failure=high hemodynamic readings 2. Cor pulmonale r/t right side of heart/pulmonary problems= high readings 4. Pulmonary hypertension- would present with high readings 5. Peripheral edema - would indicate left ventricular failure r/t high readings

You are planning a presentation about HTN which lifestyle modifications would you include? Select All 1. Limit alcohol intake 2. Regular exercise program 3. Decreased mag intake 4. Reduced K intake 5. Smoking cessation

1. Limit alcohol intake- Should limit if HTN 2. Regular exercise program- will reduce HTN 5. Smoking cessation- exacerbates HTN

You are caring for a group of PTs and should recognize which PT is at risk for a dysrhythmia? Select All 1. PT with metabolic acidosis 2. PT with K level of 4.3 3. PT whose O2 sat is 96% 4. COPD PT 5. PT who underwent a stent replacement

1. PT with metabolic acidosis-acid base imbalance = @ risk 4. COPD PT- at risk 5. PT who underwent a stent replacement- at risk

You are caring for PT with heart failure and Pt asks how should he limit his fluid to 2000ml/day. What is the best response? 1. Pour the amount of fluid you drink into an empty 2 liter bottle to keep track of how much you drink 2. Each glass contains 8 oz there are 30ml per oz so you can have a total of 8 glasses a day 3. the is the same as 2 quarts or about the same as two pots of coffee 4. Take sips of water or ice chips so you will not take too much fluid

1. Pour the amount of fluid you drink into an empty 2 liter bottle to keep track of how much you drink- provides a visual

You are providing teaching to a PT with HF you would instruct him to report what finding? 1. Weight gain of 2lbs in 24hr 2. Increase in 10mmhg in Systolic BP 3. Dyspnea with exertion 4. Dizziness when rising quickly

1. Weight gain of 2lbs in 24hr- fluid retention r/t worsen HF

A nurse is caring for a client who has severe PAD. The nurse should expect that the client will sleep most comfortably in which of the following positions? 1. With the affected limb hanging from the bed 2. With the affected limb elevated on pillows 3. With the head of the bed raised 4. In a side-lying, recumbent position

1. With the affected limb hanging from the bed-dependent position will relieve pain

A nurse is auscultating a client's heart sounds. Place the nursing actions for auscultation of the heart in the correct order. (move steps into correct order. use all steps)

1. elevate the head of the bed 30 degrees and instruct the client to breathe normally. 2. visualize the anatomy of the heart. 3. place the stethoscope to the right sternal border at the second intercostal space. 4. place the stethoscope close to the sternal border at the fourth intercostal space. 5. auscultate the apical pulse for 1 min

Heparin therapy is usually considered therapeutic when the activated partial thromboplastin time (aPTT) is how many times higher than a normal value? 0.5 to 1.5 1.5 to 2.5 2.5 to 3.5 3.5 to 4.5

1.5 to 2.5 Explanation: Heparin therapy is usually considered therapeutic when the aPTT is 1.5 to 2.5 times the normal aPTT value. The other values are not within therapeutic range

Heparin therapy is usually considered therapeutic when the activated partial thromboplastin time (aPTT) is how many times higher than a normal value? -0.5 to 1.5 -1.5 to 2.5 -2.5 to 3.5 -3.5 to 4.5

1.5 to 2.5 Explanation: Heparin therapy is usually considered therapeutic when the aPTT is 1.5 to 2.5 times the normal aPTT value. The other values are not within therapeutic range. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Deep Vein Thrombosis, pp. 846-849.

When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of: 2.5 to 3.0 times the baseline control. 3.5 times the baseline control. 4.5 times the baseline control. 1.5 to 2.5 times the baseline control.

1.5 to 2.5 times the baseline control.

When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of: -1.5 to 2.5 times the baseline control. -2.5 to 3.0 times the baseline control. -3.5 times the baseline control. -4.5 times the baseline control.

1.5 to 2.5 times the baseline control. Explanation: A normal PTT level is 21 to 35 seconds. A reading of more than 100 seconds indicates a significant risk of hemorrhage. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Deep Vein Thrombosis, p. 848

Which of the following is the preferred medication to reverse the anticoagulant effects of unfractionated heparin? A. vitamin K B. protamine sulfate C. platelet transfusion D. plasma components

2. A nurse is planning caring for a client who had a surgical placement of an synthetic graft to repair an aneurysm. Which of the following interventions should the nurse include in the plan of care? A. Assess pedal pulses. B. Monitor for an increase in pain below the graft site. C. Maintain client in high Fowler's position. D. Administer prescribed antiplatelet agents. E. Report an hourly urine output of 60 mL.

2. A. CORRECT: Pulses distal to the graft site should be monitored to detect possible occlusion of the graft. B. CORRECT: Pain below the graft site can be an indication of graft occlusion or rupture. C. INCORRECT: The head of the bed should be maintained at less than 45° to prevent flexion of the graft. D. CORRECT: Antiplatelet agents and anticoagulants are prescribed to prevent thrombus formation. E. INCORRECT: An hourly urine output of 60 mL/hr is an expected finding.

2. A nurse is caring for a client who has severe peripheral arterial disease (PAD). The nurse should expect that the client will sleep most comfortably in which of the following positions? A. With the affected limb hanging from the bed B. With the affected limb elevated on pillows C. With the head of the bed raised D. In a side-lying, recumbent position

2. A. CORRECT: The client will prefer sleeping with the affected extremity in a dependent position because this relieves pain. B. INCORRECT: This sleeping position does not promote circulation in the lower extremity. C. INCORRECT: This sleeping position does not promote circulation in the lower extremity. D. INCORRECT: This sleeping position does not promote circulation in the lower extremity.

2. A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take when there is a transfusion reaction? (Select all that apply.) A. Stop the transfusion. B. Send the blood bag and IV tubing to the blood bank. C. Maintain an IV infusion with 0.9% sodium chloride. D. Elevate the client's feet. E. Obtain blood cultures.

2. A. CORRECT: The first action is to stop the infusion. B. CORRECT: The blood bag and administration tubing are sent to the laboratory for analysis. C. CORRECT: 0.9% sodium chloride solution should be administered through new IV tubing. D. INCORRECT: The client's feet are elevated if sepsis or septic shock is suspected following a transfusion. E. INCORRECT: Blood specimens are not routinely obtained unless sepsis is suspected.

2. A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states that she is anxious because she feels that she cannot get enough air. Vital signs are: heart rate 117/min, respiratory rate 38/min, temperature 38.4° C (101.2° F), and blood pressure 100/54 mm Hg. Which of the following actions is the priority action at this time? A. Notify the provider. B. Administer heparin via IV infusion. C. Administer oxygen therapy. D. Obtain a spiral CT scan.

2. A. INCORRECT: Notifying the provider about the client's condition is important, but it is not the priority action by the nurse at this time. B. INCORRECT: Administration of IV heparin is treatment used to dissolve a blood clot, but it is not the priority action by the nurse at this time. C. CORRECT: When using the airway, breathing, circulation (ABC) priority approach to care, the nurse determines meeting the client's oxygenation needs by administering oxygen therapy is the priority action. D. INCORRECT: Obtaining a spiral CT scan to detect the presence and location of the blood clot is important, but it is not the priority action by the nurse at this time.

2. A nurse is teaching a client who has a new prescription for ferrous sulfate (Feosol). Which of the following should be included in the teaching? A. Stools will be dark red in color. B. Take with a glass of milk if gastrointestinal distress occurs. C. Foods high in vitamin C will promote absorption. D. Take for 14 days.

2. A. INCORRECT: Stools will be dark green to black in color when taking iron. B. INCORRECT: Milk binds with iron and decreases its absorption. C. CORRECT: Vitamin C enhances the absorption of iron by the intestinal tract. D. INCORRECT: Iron therapy usually takes 4 to 6 weeks for Hgb and Hct to return to the normal reference range.

2. A nurse is assessing a client and suspects the client is experiencing disseminated intravascular coagulation (DIC). Which of the following physical findings should the nurse anticipate? A. Bradycardia B. Hypertension C. Epistaxis D. Xerostomia

2. A. INCORRECT: Tachycardia is a finding that is indicative of DIC. B. INCORRECT: Hypotension is a finding that is indicative of DIC. C. CORRECT: Epistaxis is unexpected bleeding of the gums and nose and is a finding indicative of DIC. D. INCORRECT: Xerostomia is dryness of the mouth and is not indicative of DIC.

2. A nurse is caring for a client who has hemophilia. The nurse should anticipate a prescription from the provider for which of the following tests? A. RBC B. TIBC C. aPTT D. MCH

2. A. INCORRECT: The RBC identifies the presence of anemia and is not indicated for a client who has a clotting disorder. B. INCORRECT: The TIBC identifies the presence of iron deficiency anemia and is not indicated for a client who has a clotting disorder. C. CORRECT: The aPTT checks the clotting factors in a client who has hemophilia. D. INCORRECT: The MCH indicates the presence of anemia and is not indicated for a client who has a clotting disorder.

You are caring for PT with heart failure and reports increased SOB you increase O2 per protocol. What action do you do next? 1. Obtain weight 2.Assist client to high fowlers 3. Auscultate lung sounds 4. Check O2 sat with pulse ox.

2. Assist client to high fowlers- ABCs will decrease venous return to the heart(preload) and help relieve lung congestion

You are caring for a PT after CABG hemodynamic monitoring has been initiated what action would facilitate correct monitoring readings? Select all 1. Place the PT in high Fowlers 2. Level transducer to phlebostatic axis 3. Zero Transducer to room air 4. Observe trends in readings 5. compare readings to physical assessment.

2. Level transducer to phlebostatic axis 3. Zero Transducer to room air 4. Observe trends in readings 5. compare readings to physical assessment.

You are caring for a PT who is being treated for HF and has prescriptions for digoxin and furosemide. You plan to monitor for which of the following as an adverse effect of these meds? 1. SOB 2. Lightheadedness 3. Dry cough 4. Metallic taste

2. Lightheadedness- can cause a sudden drop in BP= lightheadedness

You are providing teaching to a group of PTs which of the Pts is at risk for developing PAD? 1. PT with hypothroidism 2. PT with Diabetes Mellitus 3. PT whose daily diet consists of 25% fat 4. Pt who consumes 2 bottles of beer a day

2. PT with Diabetes Mellitus-at risk for microvascular and progressive peripheral arterial disease

PT is prescribed an ace inhibitor. the RN knows the Pt understands the adverse effects when he reports the following? 1. tendon pain 2. Persistent cough 3. Frequent urination 4. constipation

2. Persistent cough - adverse effect of these meds

PT is prescribed an ace inhibitor. the RN knows the Pt understands the adverse effects when he reports the following? 1. tendon pain 2. Persistent cough 3. Frequent urination 4. constipation

2. Persistent cough- adverse effect of this drug

You are assessing a PT with Left sided heart failure. What manifestation should you expect to find? 1. Increased abdominal girth 2. Weak peripheral pulses 3. Jugular venous neck distention 4. Dependent edema

2. Weak peripheral pulses- r/t decreased CO from LSHF

You are assessing a PT with Left sided heart failure. What manifestation should you expect to find?1. Increased abdominal girth2. Weak peripheral pulses3. Jugular venous neck distention4. Dependent edema

2. Weak peripheral pulses- r/t decreased CO from LSHF

A patient has missed 2 doses of digitalis. What laboratory results would indicate to the nurse that the patient is within therapeutic range?

2.0 mg/mL For many years, digitalis was considered an essential agent for the treatment of HF, but with the advent of new medications, it is not prescribed as often. Digoxin increases the force of myocardial contraction and slows conduction through the atrioventricular node. It improves contractility, increasing left ventricular output.

When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows that therapeutic benefits will not occur for: -The first 24 hours. -At least 12 hours. -2 to 3 days. -3 to 5 days.

3 to 5 days. Explanation: It takes 3 to 5 days for a therapeutic international normalized ratio (INR) to be achieved. Therefore, Coumadin is given concurrently with heparin until a therapeutic level is established, usually within 72 hours. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Deep Vein Thrombosis, p. 848.

3. A nurse is providing discharge teaching to a client who had a gastrectomy for stomach cancer. Which of the following information should be included in the teaching? (Select all that apply.) A. "You will need a monthly injection of vitamin B12 for the rest of your life." B. "Using the nasal spray form of vitamin B12 on a daily basis may be an option." C. "An oral supplement of vitamin B12 taken on a daily basis may be an option." D. "You should increase your intake of animal proteins, legumes, and dairy products to increase vitamin B12 in your diet." E. "Add soy milk fortified with vitamin B12 to your diet to decrease the risk of pernicious anemia."

3. A. CORRECT: A client who had a gastrectomy will require monthly injections of vitamin B12 for the rest of his life. B. CORRECT: Cyanocobalamin nasal spray used daily is an option for a client who had a gastrectomy. C. INCORRECT: Oral supplements of vitamin B12 will not be absorbed due to the lack of intrinsic factor produced by the stomach. D. INCORRECT: Dietary sources of vitamin B12 will not be absorbed due to the lack of intrinsic factor produced by the stomach. E. INCORRECT: Dietary sources of vitamin B12 will not be absorbed due to the lack of intrinsic factor produced by the stomach.

3. A nurse is monitoring a client who began receiving a unit of blood 10 min ago. Which of the following should pose an immediate concern for the nurse? (Select all that apply.) A. Temperature change from 37° C (98.6° F) pretransfusion to 37.2° C (99.0° F) posttransfusion B. Dyspnea C. Heart rate increase from 74/min pretransfusion to 81/min posttransfusion D. Client report of itching E. Client appears flushed

3. A. CORRECT: A slight increase in temperature is an expected finding. B. CORRECT: Dyspnea may indicate a transfusion reaction. C. INCORRECT: A slight increase in heart rate is an expected finding. D. CORRECT: A client's report of itching may indicate a transfusion reaction. E. CORRECT: A flushed appearance of the client may indicate a transfusion reaction.

3. A nurse is teaching a client who has a new prescription for clopidogrel (Plavix). Which of the following should be included in the teaching? (Select all that apply.) A. Effects may not be apparent for several weeks. B. Monitor for the presence of black, tarry stools. C. Instruct the client to use an electric razor. D. Schedule a weekly PT test. E. Advise the client about food sources containing vitamin K.

3. A. CORRECT: Therapeutic benefits may not occur for several weeks when taking Plavix. B. CORRECT: Evidence of GI bleeding, such as abdominal pain, coffee-ground emesis, or black, tarry stools should be monitored and reported to the provider. C. INCORRECT: Bleeding precautions are required for a client taking anticoagulants, not antiplatelet medications. D. INCORRECT: PT and INR levels are monitored regularly in a client taking warfarin (Coumadin). E. INCORRECT: A client who is taking warfarin (Coumadin) should be advised about food sources containing vitamin K.

3. A nurse is discussing a new diagnosis of an aneurysm with a client. The client asks the nurse to explain what causes an aneurysm to rupture. Which of the following is an appropriate response by the nurse? A. "The wall of an artery becomes thin and flexible." B. "It is due to turbulence in blood flow in the artery." C. "It is due to abdominal enlargement." D. "It is due to hypertension."

3. A. INCORRECT: An aneurysm ruptures as a result of thickening in the intima of the artery and a lack of elasticity in the vessel wall, which is usually under pressure due to hypertension. B. INCORRECT: A bruit is objective data, which indicates the presence of an aneurysm, not the cause of rupture. C. INCORRECT: Abdominal distention may occur when an aneurysm ruptures, but it is not the cause of the rupture. D. CORRECT: Hypertension increases pressure within the arterial walls, resulting in rupture.

3. A nurse is caring for a client who has idiopathic thrombocytopenic purpura (ITP). The nurse should notify the provider and report possible small-vessel clotting when which of the following is assessed? A. Petechiae on the upper chest B. Hypotension C. Cyanotic nail beds D. Severe headache

3. A. INCORRECT: Petechiae on the upper chest can indicate impaired clotting. B. INCORRECT: Hypotension can indicate impaired clotting. C. CORRECT: Cyanotic nail beds indicate microvascular clotting is occurring and should be immediately reported to avoid ischemic loss of the fingers or toes. D. INCORRECT: Severe headache can indicate cerebral bleeding.

3. A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? A. "I am allergic to morphine." B. "I take antacids several times a day." C. "I had a blood clot in my leg several years ago." D. "It hurts to take a deep breath."

3. A. INCORRECT: The nurse should document all allergies. Morphine can be prescribed to manage the client's discomfort due to a blood clot, but is not the immediate concern at this time. B. CORRECT: The greatest risk to the client is the possibility of bleeding from a peptic ulcer. Further assessment should be completed and the nurse should notify the provider of the finding. C. INCORRECT: The client's history of a blood clot is important for the nurse to know, but it is not the immediate concern at this time. D. INCORRECT: The client report of pain with breathing is important for the nurse to know, but it is not the immediate concern at this time.

3. A nurse is providing teaching for a client who is to have a bone marrow biopsy of the iliac crest. Which of the following statements made by the client indicates a need for further teaching? A. "Cancer can be detected in the fluid being tested." B. "I will feel a heavy pressure sensation in my hip bone." C. "The type of antibiotic I need to take can be determined by this test." D. "I will be awake during the procedure."

3. A. INCORRECT: The presence of cancer can be determined by this test. B. INCORRECT: The client will feel brief pain or pressure with this test. C. CORRECT: A culture and sensitivity test determines the type of antibiotics that a client who has an infection needs to take. D. INCORRECT: A client is awake during a bone marrow biopsy.

You are reviewing the lab results of several PTs who have PAD. You plan to provide dietary teaching for the PT with which of the following? 1. Cholesterol 180mg, HDL 70mg, LDL 90mg 2.Cholesterol 185mg, HDL 50mg, LDL 120mg 3.Cholesterol 190mg, HDL 25mg, LDL 160mg 4.Cholesterol 195mg, HDL 55mg, LDL 125mg

3. Cholesterol 190mg, HDL 25mg, LDL 160mg** cholesterol should be less than 200HDL above 40LDL less than 100

You are caring for a patient who is scheduled for a CABG in 2hr. Which PT statement needs further clarification? 1. My arthritis is really bothering me b/c i haven't taken my aspirin in a week 2. My BP shouldn't be high b/c i took my BPmeds this morning 3. I took my warfarin last night according to my schedule. 4. I will check my blood sugar b/c i took a reduced dose of insulin this morning

3. I took my warfarin last night according to my schedule.- should have stopped 5-7 days prior for bleeding

The RN is teaching a student on the care of a PT who is receiving hemodynamic monitoring. Which statement indicates teaching was effective? 1. Air should be instilled into the monitoring system 2. The client should be in the prone position 3. The transducer should be level with the 2nd intercostal space 4. A chest X-ray is needed to verify placement.

4. A chest X-ray is needed to verify placement.

4. A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following medications should the nurse anticipate administering to the client? A. Heparin B. Vitamin K C. Antibiotic D. Antilipemic

4. A. CORRECT: Heparin may be administered to decrease the formation of microclots, which deplete clotting factors. B. INCORRECT: Vitamin K promotes blood coagulation and is not a medication that is prescribed for a client who has DIC. C. INCORRECT: An antibiotic is given to treat bacterial infections and is not a medication that the nurse should anticipate being administered to a client who has DIC. D. INCORRECT: An antilipemic is given to treat hyperlipidemia and is not a medication that the nurse should anticipate being administered to a client who has DIC.

4. A nurse is completing an integumentary assessment of a client who has anemia. Which of the following is an expected finding? A. Absent turgor B. Spoon-shaped nails C. Shiny, hairless legs D. Yellow mucous membranes

4. A. INCORRECT: Absent skin turgor is a finding in a client who has dehydration. B. CORRECT: Deformities of the nails, such as being spoon-shaped, are a finding in a client who has anemia. C. INCORRECT: These findings are present in a client who has peripheral vascular disease. D. INCORRECT: The client who has anemia will have pale nail beds and mucous membranes.

4. A nurse is admitting a client with a suspected occlusion of a graft of the abdominal aorta. Which of the following is an expected clinical finding? A. Increased urine output B. Bounding pedal pulse C. Increased abdominal girth D. Redness of the lower extremities

4. A. INCORRECT: Decreased urine output is an expected finding with occlusion of a graft of the aorta. B. INCORRECT: Decreased or absent pedal pulse is an expected finding with occlusion of a graft of the aorta. C. CORRECT: Abdominal distention is an expected finding with occlusion of a graft of the aorta. D. INCORRECT: Pallor or cyanosis of the extremities is an expected finding with occlusion of a graft of the aorta.

Which diagnostic study is usually performed to confirm the diagnosis of heart failure?

Encocardiogram

4. A nurse is assessing a client who has a pulmonary embolism. Which of the clinical manifestations should the nurse expect to find? (Select all that apply.) A. Bradypnea B. Pleural friction rub C. Hypertension D. Petechiae E. Tachycardia

4. A. INCORRECT: Tachypnea is a clinical manifestation associated with a pulmonary embolism. B. CORRECT: A pleural friction rub is a clinical manifestation associated with a pulmonary embolism. C. INCORRECT: Hypotension is a clinical manifestation associated with a pulmonary embolism. D. CORRECT: Petechiae is a clinical manifestation associated with a pulmonary embolism. E. CORRECT: Tachycardia is a clinical manifestation associated with a pulmonary embolism.

4. A nurse is completing preoperative teaching with a client who will undergo an elective surgical procedure that will include a blood transfusion. Which of the following statements by the nurse should be included in the teaching? A. "You should make an appointment to donate blood 8 weeks prior to the surgery." B. "If you need an autologous transfusion, the blood your brother donates can be used." C. "We will have you come in to donate your blood the day before surgery." D. "You will receive the blood you donated 4 weeks prior to the surgery."

4. A. INCORRECT: The client should donate blood for an autologous transfusion no sooner than 5 weeks in advance, up to 72 hr prior to surgery. B. INCORRECT: A homologous transfusion involves receiving a transfusion of blood from donors other than the recipient. C. INCORRECT: The client should donate blood for an autologous transfusion no sooner than 5 weeks in advance, up to 72 hr prior to surgery. D. CORRECT: An autologous transfusion involves collecting a client's blood no sooner than 5 weeks in advance, up to 72 hr prior to surgery so it can be transfused during an elective surgery.

4. A nurse is caring for a client who has a deep-vein thrombosis (DVT) and has been taking unfractionated heparin for 1 week. Two days ago, the provider also prescribed warfarin (Coumadin). The client questions the nurse about receiving both heparin and warfarin at the same time. Which of the following is an appropriate response by the nurse? A. "I will remind your provider that you are already receiving heparin." B. "Laboratory findings indicated that two anticoagulants were needed." C. "It takes three or four days before the effects of warfarin are achieved and the heparin can be discontinued." D. "Only one of these medications is being given to treat your deep-vein thrombosis."

4. A. INCORRECT: Warfarin is prescribed for 3 to 4 days before discontinuing IV heparin. B. INCORRECT: IV heparin is monitored to achieve adequate therapeutic levels in treating a DVT. C. CORRECT: Warfarin depresses synthesis of clotting factors but does not have an effect on clotting factors that are present. Therefore, it takes 3 to 4 days before the clotting factors that are present decay and the therapeutic effects of warfarin occur. D. INCORRECT: Heparin and warfarin are both effective in treating DVTs.

4. A nurse is caring for a client who is having a bone marrow biopsy. What actions should the nurse take? Use the ATI Active Learning Template: Diagnostic Procedure to complete this item to include the following: A. Nursing Interventions: Describe two for each of the pre, intra, and postoperative periods. B. Potential Complications: Identify two. C. Client Education: Describe two teaching points.

4. Using the ATI Active Learning Template: Diagnostic Procedure A. Nursing Interventions ●● Pre ◯◯ Ensure that the client has signed the informed consent form. ◯◯ Position the client in a prone or side-lying position. ●● Intra ◯◯ Administer sedative medication. ◯◯ Assist with the procedure. ◯◯ Apply pressure to the biopsy site. ◯◯ Place a sterile dressing over the biopsy site. ●● Post ◯◯ Monitor for evidence of infection and bleeding. ◯◯ Apply ice to the biopsy site. ◯◯ Administer mild analgesics; avoid aspirin or medications that affect clotting. B. Potential Complications ●● Bleeding and infection C. Client Education ●● Explain the procedure to be performed: use of local anesthesia, sensation of pressure or brief pain. ●● Report excessive bleeding and evidence of infection to the provider. ●● Check the biopsy site daily. It should be clean, dry and intact. ●● If there are sutures, return in 7 to 10 days for removal.

You are teaching a PT the importance of remaining still following angiography. Which statement is the best to say? 1. Moving in bed raises your BP 2. Too much activity increases your risk for infection. 3. moving in bed increases your risk of a complication due to anesthesia 4. too much activity places you at risk for bleeding

4. too much activity places you at risk for bleeding

Beginning warfarin concomitantly with heparin can provide a stable INR by which day of heparin treatment? 2 3 4 5

5. A nurse is caring for a client who is to receive fibrinolytic thrombolytic therapy. Which of the following should the nurse recognize as a contraindication to the therapy? A. Hip arthroplasty 2 weeks ago B. Elevated sedimentation rate C. Incident of exercise-induced asthma 1 week ago D. Elevated platelet count

5. A. CORRECT: Clients who have undergone a major surgical procedure within the last 3 weeks should not receive thrombolytic therapy because of the risk of hemorrhage from the surgical site. B. INCORRECT: An elevated sedimentation rate does not place the client at risk for hemorrhage. C. INCORRECT: An incident of exercise-induced asthma does not place the client at risk for hemorrhage. D. INCORRECT: An elevated platelet count does not place the client at risk for hemorrhage.

5. A nurse is reviewing clinical manifestations of a thoracic aortic aneurysm with a newly hired nurse. Which of the following should the nurse include in the discussion? (Select all that apply.) A. Cough B. Shortness of breath C. Upper chest pain D. Diaphoresis E. Altered swallowing

5. A. CORRECT: Cough is a manifestation of a thoracic aortic aneurysm. B. CORRECT: Shortness of breath is a manifestation of a thoracic aortic aneurysm. C. INCORRECT: Report of severe back pain is a clinical finding of thoracic aortic aneurysm. D. INCORRECT: Diaphoresis is a clinical finding of dissecting aortic aneurysm. E. CORRECT: Difficulty swallowing is a manifestation of a thoracic aortic aneurysm.

5. A nurse is observing a newly hired nurse on the unit who is preparing to administer a blood transfusion. Which of the following actions by the newly hired nurse requires intervention by the nurse? A. Inserts a large-bore IV catheter in the client B. Verifies blood compatibility and expiration date of the blood with an assistive personnel (AP) C. Administers 0.9% sodium chloride IV D. Assesses for a history of blood-transfusion reactions

5. A. INCORRECT: A large-bore IV catheter is used for administering blood products. B. CORRECT: Verification of the client's identify, blood compatibility, and expiration date of the blood is done with another nurse. Assistive personnel cannot be asked to perform this task. C. INCORRECT: Blood and blood products are infused with 0.9% sodium chloride. IV solutions containing dextrose cannot be used. D. INCORRECT: The nurse should assess for a client history of blood-transfusion reactions to identify any potential risks for future reactions.

5. A nurse is caring for a client who has chronic venous insufficiency. The provider prescribed thigh-high compression stockings. The nurse should instruct the client to A. massage both legs firmly with lotion prior to applying the stockings. B. apply the stockings in the morning upon awakening and before getting out of bed. C. roll the stockings down to the knees if they will not stay up on the thighs. D. remove the stockings while out of bed for 1 hr, four times a day to allow the legs to rest.

5. A. INCORRECT: Massaging the affected area can dislodge a clot and cause embolism. B. CORRECT: Applying stockings in the morning upon awakening and before getting out of bed reduces venous stasis and assists in the venous return of blood to the heart. Legs are less edematous at this time. C. INCORRECT: Rolling stockings down can restrict circulation and cause edema. D. INCORRECT: Stockings should remain in place throughout the day and are removed before going to bed to provide continuous venous support. If the stockings are removed, such as for a bath or shower, then the legs should be elevated before the stockings are reapplied.

5. A nurse in a clinic receives a phone call from a client seeking information about his new prescription for erythropoietin (Epogen). Which of the following information should be reviewed with the client? A. The client needs an erythrocyte sedimentation rate (ESR) test weekly. B. The client should have his hemoglobin checked twice a week. C. Oxygen saturation levels should be monitored. D. Folic acid production will increase.

5. A. INCORRECT: The effectiveness of erythropoietin is evaluated by changes in the hematocrit. B. CORRECT: Hemoglobin and hematocrit are monitored twice a week. C. INCORRECT: Blood pressure is monitored for an increase. D. INCORRECT: Erythropoietin promotes increased production of RBCs.

5. A nurse is developing a plan of care for a client who has disseminated intravascular coagulation (DIC). Which interventions should the nurse include in the plan of care? Use the ATI Active Learning Template: Systems Disorder to complete this item to include Patient-Centered Care: Describe five interventions.

5. Using ATI Active Learning Template: Systems Disorder ●● Patient-Centered Care ◯◯ Monitor for signs of microemboli (cyanotic nail beds, pain). Regularly take vital signs and assess hemodynamic status. ◯◯ Monitor for signs of organ failure or intracranial bleed (oliguria, decreased level of consciousness). ◯◯ Monitor laboratory values for clotting factors. ◯◯ Administer fluid volume replacement. ◯◯ Transfuse blood, platelets, and other clotting products. ◯◯ Monitor for complications from the administration of blood and blood products. ◯◯ Avoid use of NSAIDs. ◯◯ Administer supplemental oxygen. ◯◯ Provide protection from injury. ◯◯ Instruct client to avoid Valsalva maneuver (could cause cerebral hemorrhage). ◯◯ Implement bleeding precautions (avoid use of needles).

Approximately what percentage of the arterial lumen must be obstructed before intermittent claudication is experienced? 20 30 40 50

In a client with a bypass graft, the distal outflow vessel must have at least what percentage patency for the graft to remain patent? 20 30 40 50

In a patient with a bypass graft, the distal outflow vessel must be at least what percentage patent for the graft to remain patent? a) 40 b) 20 c) 50 d) 30

50 The distal outflow vessel must be at least 50% patent for the graft to remain patent.

In a client with a bypass graft, the distal outflow vessel must have at least what percentage patency for the graft to remain patent? -20 -30 -40 -50

50 Explanation: The distal outflow vessel must be at least 50% patent for the graft to remain patent. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Peripheral Artery Disease, pp. 833-836.

A nursing instructor is discussing the diagnosis of intermittent claudication with students. To determine whether the students understand the pathophysiology of the disease, the instructor asks, "What percentage of the arterial lumen must be obstructed before intermittent claudication is experienced?" What answer should the students give? -20 -30 -40 -50

50 Explanation: Typically, about 50% of the arterial lumen or 75% of the cross-sectional area must be obstructed before intermittent claudication is experienced. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Assessment of the Vascular System, p. 822.

Approximately what percentage of the arterial lumen must be obstructed before intermittent claudication is experienced? -20 -30 -40 -50

A client has had an echocardiogram to measure ejection fraction. The nurse explains that ejection fraction is the percentage of blood the left ventricle ejects upon contraction. What is the typical percentage of blood a healthy heart ejects?

55% Normally, a healthy heart ejects 55% or more of the blood that fills the left ventricle during diastole.

6. A nurse is caring for a client who is receiving a blood transfusion. What nursing actions should the nurse anticipate if a transfusion reaction is suspected? Use the ATI Active Learning Template: Nursing Skill to complete this item to include the following: A. Indications: ●● Describe the four types of reactions and the time of onset. ●● Describe three medications that may be administered and for which reaction. B. Potential Complications: Describe two nursing actions for each.

6. Using the ATI Active Learning Template: Nursing Skill A. Indications ●● Types of reactions and onset ◯◯ Acute hemolytic - immediate ◯◯ Febrile - 30 min to 6 hr after transfusion ◯◯ Mild allergic - During or up to 24 hr after transfusion ◯◯ Anaphylactic - immediate B. Potential Complications ●● Circulatory overload ◯◯ Administer oxygen. ◯◯ Monitor vital signs. ◯◯ Slow the infusion rate. ◯◯ Administer diuretics as prescribed. ◯◯ Notify the provider immediately. ●● Medications ◯◯ Antipyretics (acetaminophen [Tylenol]) - febrile ◯◯ Antihistamines (diphenhydramine [Benadryl]) - mild allergic ◯◯ Antihistamines, corticosteroids, vasopressors - anaphylactic ●● Sepsis and septic shock ◯◯ Maintain patent airway. ◯◯ Administer oxygen. ◯◯ Administer antibiotics as prescribed. ◯◯ Obtain blood samples for culture. ◯◯ Administer vasopressors in late phase. ◯◯ Elevate client's feet. ◯◯ Assess for disseminated intravascular coagulation.

6. A nurse is developing a poster presentation on peripheral arterial disease (PAD) for a community health fair. What content should the nurse include on the poster? Use ATI Active Learning Template: Systems Disorder to complete this item to include the following: A. Description of Disease Process B. Risk Factors: Describe at least six. C. Objective Data: Describe at least six findings. D. Client Education: Describe at least two actions by the client related to proper positioning and two actions related to promoting vasodilation.

6. Using the ATI Active Learning Template: Systems Disorder A. Description of Disease Process: PAD is inadequate blood flow of the lower extremities due to atherosclerosis. The intima and media of the arteries becomes thickened, and plaques may form on the walls of the arteries, making them rough and fragile. The arteries progressively stiffen and the lumen narrows, decreasing blood supply to tissues and increasing resistance to blood flow. It is classified as either an inflow or outflow type of PAD. B. Risk Factors ●● Hypertension ●● Hyperlipidemia ●● Diabetes mellitus ●● Cigarette smoking ●● Obesity ●● Sedentary lifestyle ●● Familial predisposition ●● Age C. Objective Data ●● Bruits over femoral and aortic arteries ●● Decreased capillary refill of toes (greater than 3 seconds) ●● Decreased or nonpalpable pulses ●● Loss of hair on the lower extremities ●● Dry, scaly mottled skin ●● Thick toenails ●● Cold, cyanotic extremity ●● Pallor of extremity with elevation ●● Dependent rubor ●● Muscle atrophy ●● Ulcers and possible gangrene of toes D. Client Education ●● Actions related to positioning ◯◯ Avoid crossing the legs. ◯◯ Avoid wearing restrictive garments. ◯◯ Keep legs elevated to reduce swelling but not above the level of the heart. ●● Actions to promote vasodilation ◯◯ Maintain a warm environment. ◯◯ Wear insulated socks. ◯◯ Avoid applying direct heat to the extremity. ◯◯ Avoid exposure to cold. ◯◯ Avoid stress, caffeine, and nicotine.

6. A nurse educator is presenting a community education program on anemia to a group of clients. What should be included in this presentation? Use the ATI Active Learning Template: Systems Disorder to complete this item to include the following: A. Description of Disorder/Disease Process: Describe and identify at least three causes. B. Objective and Subjective Data: Identify at least three of each form of data. C. Laboratory Tests: Describe the importance of the TIBC test.

6. Using the ATI Active Learning Template: Systems Disorder A. Description of Disorder/Disease Process ●● Anemia is an abnormally low amount of circulating red blood cells, hemoglobin concentration, or both. It may be due to blood loss, inadequate production or increased destruction of red blood cells, and dietary deficiencies of folic acid, iron, erythropoietin, and/or vitamin B12. B. Objective and Subjective Data ●● Objective Data ◯◯ Shortness of breath and fatigue with exertion ◯◯ Tachycardia, palpitations, dizziness, or syncope upon standing or with exertion ◯◯ Pallor, pale nail beds, pale mucous membranes, nail bed deformities ◯◯ Smooth, sore, bright-red tongue ●● Subjective Data ◯◯ May be asymptomatic, pallor, fatigue, irritability, numbness and tingling of extremities, dyspnea on exertion, sensitivity to cold, pain, and hypoxia with sickle-cell crisis C. Laboratory Tests ●● This test is an indirect measurement of serum transferrin, a protein that binds with iron and transports it for storage. Serum transferrin is an indicator of the total iron stores in the body.

6. A nurse educator is presenting a program to nurses on care of the client with an aneurysm. What should the educator include in this program? Use the ATI Active Learning Template: Systems Disorder to complete this item to include the following sections: A. Risk Factors: Describe three. B. Diagnostic Procedures: Describe two. C. Nursing Interventions: Describe at least four.

6. Using the ATI Active Learning Template: Systems Disorder A. Risk Factors ●● Male sex ●● Atherosclerosis ●● Uncontrolled hypertension ●● Tobacco use ●● Age-related changes to the artery (loss of elastin, thickening of the intima, progressive fibrosis) B. Diagnostic Procedures ●● X-rays ●● CT scans ●● Ultrasonography C. Nursing Interventions ●● Take vital signs every 15 min until stable. Then, every hour, monitoring for increased blood pressure. ●● Assess pain (onset, quality, duration, severity). ●● Assess temperature, circulation, and range of motion of extremities. ●● Monitor cardiac rhythm continuously. ●● Monitor hemodynamic findings. ●● Monitor ABGs, Sa02, electrolytes, CBC laboratory findings. ●● Monitor hourly urine output. ●● Administer oxygen as prescribed. ●● Obtain and maintain IV access. ●● Administer medications as prescribed.

6. A nurse is caring for a client who has a pulmonary embolism. Use the ATI Active Learning Template: Systems Disorder to complete this item to include the following sections: A. Description of Disorder/Disease Process B. Patient-Centered Care: ●● Describe three nursing interventions. ●● Identify two medications.

6. Using the Active Learning Template: Systems Disorder A. Description of Disorder/Disease Process ●● A pulmonary embolism (PE) occurs when a substance (solid, gaseous, or liquid) enters venous circulation and forms a blockage in the pulmonary vasculature. ●● Emboli originating from deep-vein thrombosis (DVT) are the most common cause. Tumors, bone marrow, amniotic fluid, and foreign matter can also become emboli. B. Patient-Centered Care ●● Nursing Interventions ◯◯ Administer oxygen therapy as prescribed to relieve hypoxemia and dyspnea. Position the client to maximize ventilation (high-Fowler's = 90%). ◯◯ Initiate and maintain IV access. ◯◯ Administer medications as prescribed. ◯◯ Provide emotional support and comfort to control client anxiety. ◯◯ Monitor changes in level of consciousness and mental status. ●● Medications ◯◯ Anticoagulants - enoxaparin (Lovenox), heparin, and warfarin (Coumadin) ◯◯ Thrombolytic therapy - alteplase (Activase) and streptokinase (Streptase)

Explanation: Peripheral artery disease (PAD) is defined as arterial insufficiency of the extremities that occurs most often in men and is a common cause of disability. Appropriate nursing actions to increase arterial blood supply to the client's extremities include keeping the legs in a dependent position and encouraging physical activity. Keeping legs in a dependent position enhances arterial blood supply, while exercise promotes blood flow and the development of collateral circulation. Appropriate nursing actions to promote vasodilation and prevent vascular compression include wearing warm clothing when it is cold, discouraging the use of nicotine products, and advising the client to avoid crossing the legs. Warmth promotes arterial flow by preventing vasoconstriction from chilling; nicotine causes vasospasm, which decreases circulation; and crossing the legs causes compression of vessels with the subsequent impediment of circulation, resulting in venous stasis. Keeping warm, discouraging the use of nicotine products, and telling the client to avoid crossing the legs are nursing actions more appropriate to promote vasodilation and prevent vascular compression versus increasing arterial blood supply to the extremities. Keeping the legs in a dependent position and encouraging physical activity daily are interventions that increase arterial blood supply to the extremities versus promoting vasodilation and preventing vascular compression.

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All of the following are associated with secondary Raynaud phenomenon except: A. hypertension B. scleroderma C. repeated use of vibrating tools D. use of beta adrenergic antagonists

Clinical presentation of lower extremity atherosclerotic arterial disease most likely includes: A. pain and paresthesia B. pallor and pulselessness C. poikilothermy D. paralysis and loss of limb strength

Compared with unfractionated heparin, characteristics of low-molecular-weight heparin (LMWH) include all of the following except: A. more antiplatelet effect. B. decreased need for monitoring of anticoagulant effect. C. longer half-life. D. superior bioavailability.

Lifestyle modification for patients with Raynaud phenomenon includes: A. discontinuing cigarette smoking B. increasing fluid intake C. avoiding placing hands in warm water D. discontinuing ASA use

More common etiologies of PAD include: A. arterial embolism and underlying atrial fibrillation B. chronic venous insufficiency C. extension of venous thrombosis D. vessel trauma

Treatment of superficial venous thrombophlebitis in a low-risk, stable patient includes use of: A. compression stockings. B. acetaminophen. C. warfarin. D. heparin.

Typically, the earliest sign of venous insufficiency is: A. edema B. altered pigmentation C. skin atrophy D. shiny skin

When taken concomitantly with warfarin, which causes a possible decreased anticoagulant effect? A. cholestyramine B. allopurinol C. cefpodoxime D. zolpdem

When taken with warfarin, which causes a possible increased anticoagulant effect? A. clarithromycin B. carbamazepine C. pravastatin D. sucralfate

Which of the following is the most likely to be found in deep vein thrombophlebitis (DVT)? A. unilateral leg edema B. leg pain C. warmth over the affected area D. positive obturator sign

Which of the following is the preferred medication to reverse the anticoagulant effects of warfarin? A. vitamin K B. protamine sulfate C. platelet transfusion D. plasma components

Which client would be most likely to develop an abdominal aortic aneurysm?

A 69-year-old male with peripheral vascular disease

The nurse is reviewing the medication administration record of a client diagnosed with systolic heart failure. Which medication would the nurse anticipate administering to this client?

A beta-adrenergic blocker

A nurse is assessing the anterior chest of a client. Which of the following findings should the nurse report to the provider?

A forceful chest movement at the midclavicular line in the fourth intercostal space

A nurse suspects the presence of an abdominal aortic aneurysm. What assessment data would the nurse correlate with a diagnosis of abdominal aortic aneurysm? (Select all that apply.) -A pulsatile abdominal mass -Low back pain -Decreased bowel sounds -Lower abdominal pain -Diarrhea

A pulsatile abdominal mass Low back pain Lower abdominal pain Explanation: Some patients complain that they can feel their heart beating in their abdomen when lying down, or they may say that they feel an abdominal mass or abdominal throbbing. The most important diagnostic indication of an abdominal aortic aneurysm is a pulsatile mass in the middle and upper abdomen. Signs of impending aneurysm rupture include severe back or abdominal pain, which may be persistent or intermittent. Abdominal pain is often localized in the middle or lower abdomen to the left of the midline. Low back pain may be present because of pressure of the aneurysm on the lumbar nerves. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Abdominal Aortic Aneurysm, p. 840.

The nurse is assessing a client with severe hypertension. Which symptom indicates to the nurse that the client is experiencing dissection of the aorta? -Gradual onset of a frontal headache -Numbness and pain of the left arm -A ripping sensation in the chest -Pain when flexing the neck forward

A ripping sensation in the chest Explanation: Aortic dissections are commonly associated with poorly controlled hypertension. Dissection is caused by rupture in the intimal layer. A rupture may occur through adventitia or into the lumen through the intima, allowing blood to reenter the main channel and resulting in chronic dissection or occlusion of branches of the aorta. The onset of symptoms is usually sudden and described as severe, persistent pain that feels like tearing or ripping. An aortic dissection does not cause pain and numbness of the left arm. Pain when flexing the neck forward is not associated with an aortic dissection. An aortic dissection does not cause a headache. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Aortic Dissection, p. 842.

When assessing the client with pericardial effusion, the nurse will assess for pulsus paradoxus. Pulsus paradoxus is characterized by what assessment finding?

A systolic blood pressure that is lower during inhalation

What is some expected assessment findings of cariogenic shock? Select All 1. tachycardia 2. hypotension 3.crackles 4. angina 5. cool and clammy skin

ALL OF THEM**Cardiogenic shock- complication of pump failure that occurs commonly after MI and injury greater than 40% to the left ventricle. - treat with vasopressors and interpose (digoxin) to increase CO to maintain organ perfusion

Which assessment finding by the nurse is the most significant finding suggestive of aortic aneurysm? -Nausea and vomiting -Abdomen bruit -Severe back pain -High blood pressure

Abdomen bruit Explanation: A pulsating mass or a bruit in the abdomen over the mass is most suggestive of aortic aneurysm. Severe back pain, nausea, and high blood pressure are all symptoms associated with aortic aneurysm but not as independently suggestive. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Abdominal Aortic Aneurysm, p. 840.

Which assessment data would the nurse recognize to support the diagnosis of abdominal aortic aneurysm?

Abdominal bruit.

The nurse is caring for a client recovering from surgery to treat aortoiliac disease. Which assessment findings indicate to the nurse that manual manipulation of the bowel occurred during the surgery? Select all that apply. -Abdominal distention -Absence of bowel sounds -Liquid bowel movement -Coffee-ground emesis -Left lower quadrant pain

Abdominal distention Absence of bowel sounds Explanation: The treatment of aortoiliac disease is essentially the same as that for atherosclerotic PAD. If there is significant aortic disease, the surgical procedure of choice is the aortoiliac graft. If possible, the distal graft is anastomosed to the iliac artery, and the entire surgical procedure is performed within the abdomen. Because of this, abdominal assessment for bowel sounds and paralytic ileus is to be done at least every 8 hours. Abdominal distention and the absence of bowel sounds indicate paralytic ileus. Coffee-ground emesis is an indication of gastrointestinal bleeding which is not associated with surgery to treat aortoiliac disease. A liquid bowel movement may indicate bowel ischemia which is caused by an occlusion of the mesenteric blood supply. Left lower quadrant abdominal pain is not associated with treatment of aortoiliac disease. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Aortoiliac Disease, p. 838.

Which assessment data would require immediate intervention by the nurse for the client who is six (6) hours postoperative abdominal aortic aneurysm repair?

Absent bilateral pedal pulse

The nurse has entered a client's room and found the client unresponsive and not breathing. What is the nurse's next appropriate action?

Activate the Emergency Response System (ERS).

A cardiac client's resistance to left ventricular filling has caused blood to back up into the client's circulatory system. Which health problem is likely to result?

Acute pulmonary edema

A client presents to the ED reporting increasing shortness of breath. The nurse assessing the client notes a history of left-sided heart failure. The client is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem?

Acute pulmonary edema

A client with left-sided heart failure reports increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of what condition?

Acute pulmonary edema

A nurse is assisting in the care of a client who had an abdominal aortic aneurysm and is scheduled for surgery. The clients vital signs are blood pressure 160/98 mm Hg, heart rate 102/min, respirations 22/min, and SpO2 95%. Which of the following actions should the nurse take?

Administer antihypertensive medication for the blood pressure

A client in the emergency room is in cardiac arrest and exhibiting pulseless electrical activity (PEA) on the cardiac monitor. What will be the nurse's next action?

Administer epinephrine

The nurse is administering sublingual nitroglycerin to a client with chest pain. What action will the nurse take after administering two sublingual tablets if the client continues with chest pain and has a blood pressure of 120/82 mm Hg?

Administer the third sublingual nitroglycerin tablet.

Which of the following diagnostic tests are used to quantify venous reflux and calf muscle pump ejection? a) Lymphangiography b) Air plethysmography c) Lymphoscintigraphy d) Contrast phlebography

Air plethysmography Air plethysmography is used to quantify venous reflux and calf muscle pump action. Contrast phlebography involves injecting a radiopaque contrast agent into the venous system. Lymphoscintigraphy is done when a radioactively labeled colloid is injected subcutaneously in the second interdigital space. The extremity is then exercised to facilitate the uptake of the colloid by the lymphatic system, and serial images are obtained at present intervals. Lymphoangiography provides a way of detecting lymph node involvement resulting from metastatic carcinoma, lymphoma, or infection in sites that are otherwise inaccessible to the examiner except by surgery.

The nurse explains to a patient that the primary cause of a varicose vein is: Venospasm. An incompetent venous valve. Venous occlusion. Phlebothrombosis.

An incompetent venous valve.

Which of the following medications is considered a thrombolytic? Lovenox Alteplase Coumadin Heparin

Alteplase

Which of the following medications is considered a thrombolytic? -Lovenox -Alteplase -Coumadin -Heparin

Alteplase Explanation: Alteplase is considered a thrombolytic, which lyses and dissolves thrombi. Thrombolytic therapy is most effective when given within the first 3 days after acute thrombosis. Heparin, Coumadin, and Lovenox do not lyse clots. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Deep Vein Thrombosis, p. 849.

A patient is admitted to a special critical care unit for the treatment of an arterial thrombus. The nurse is aware that the preferred drug of choice for clot removal, unless contraindicated, would be: Streptokinase Reteplase. Urokinase. Alteplase.

Alteplase.

Alteplase. Explanation: Alteplase has fewer disadvantages than the other thrombolytic agents. Refer to Table 18-2 in the text. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Deep Vein Thrombosis, p. 849.

A total artificial heart (TAH) is an electrically powered pump that circulates blood into the pulmonary artery and the aorta, thus replacing the functions of both the right and left ventricles. What makes it different from an LVAD?

An LVAD only supports a failing left ventricle. A TAH is considered an extension of LVADs, which only support a failing left ventricle. TAHs are targeted for clients who are unlikely to live more than a month without further interventions.

The nurse is performing a physical assessment on a client suspected of having heart failure. The presence of which sound would tend to confirm the suspicion for heart failure?

An S3 heart sound

A client has been experiencing increasing shortness of breath and fatigue. The health care provider has ordered a diagnostic test in order to determine what type of heart failure the client is having. What diagnostic test does the nurse anticipate being ordered?

An echocardiogram

Which aneurysm occurs as a result of infection at arterial suture or graft sites? a) Dissecting b) Anastomotic c) False d) Saccular

Anastomotic An anastomotic aneurysm occurs as a result of infection at arterial suture or graft sites. Dissection results from a rupture in the intimal layer, resulting in bleeding between the intimal and medial layers of the arterial wall. Saccular aneurysms collect blood in the weakened outpouching. In a false aneurysm, the mass is actually a pulsating hematoma

To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the: Outside of the foot just below the heel. Anterior surface of the foot near the ankle joint. Inside of the ankle just above the heel. Exterior surface of the foot near the heel.

Anterior surface of the foot near the ankle joint.

To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the: -Outside of the foot just below the heel. -Exterior surface of the foot near the heel. -Inside of the ankle just above the heel. -Anterior surface of the foot near the ankle joint.

Anterior surface of the foot near the ankle joint. Explanation: The dorsalis pedis pulse can be palpated on the dorsal surface of the foot distal to the major prominence of the navicular bone. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Doppler Ultrasound Flow Studies, p. 824.

1. A nurse in the emergency department is assisting with the admission of a client who has a possible dissecting abdominal aortic aneurysm. Which of the following is the priority nursing intervention? A. Administer pain medication as prescribed. B. Ensure a warm environment. C. Administer IV fluids as prescribed. D. Initiate a 12-lead ECG.

Application Exercises Key 1. A. INCORRECT: Administering pain mediation is important, but it is not the priority nursing intervention. B. INCORRECT: Ensuring a warm environment is important, but it is not the priority nursing intervention. C. CORRECT: Using the ABC priority-setting framework, the greatest risk to the client is inadequate circulatory volume. The priority nursing intervention is to administer IV fluids. D. INCORRECT: Initiating a 12-lead ECG is important, but it is not the priority nursing intervention.

The nurse is discussing cardiac hemodynamics with a nursing student. The nurse explains preload to the student and then asks the student what nursing interventions might cause increased preload. Which response by the student indicates understanding?

Application of antiembolic stockings Preload is the amount of blood presented to the ventricles just before systole. Anything that assists in returning blood to the heart (e.g., antiembolic stockings) or preventing blood from pooling in the extremities will increase preload. Anything that decreases the amount of blood returning to the heart will decrease preload, such as vasodilation or blood pooling in the extremities.

The nurse is performing a respiratory assessment for a patient in left-sided heart failure. What does the nurse understand is the best determinant of the patient's ventilation and oxygenation status?

Arterial blood gases

A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following? a) Neither venous nor arterial b) Trauma c) Arterial insufficiency d) Venous insufficiency

Arterial insufficiency Characteristics of arterial insuffiency ulcers include location at the tips of the toes, extreme painfulness, and circular shape with pale to black ulcer bases. Ulcers caused by venous insufficiency will be irregular in shape, minimal pain if superficial (can be painful), and usually located around the ankles or the anterier tibial area.

A home health nurse is seeing an elderly female client for the first time. During the physical assessment of the client's feet, the nurse notes several circular ulcers around the tips of the toes on both feet. The bases of the ulcers are pale, and the client reports the ulcers to be very painful. From these assessment findings, the nurse suspects that the cause of the ulcers is which of the following? -Neither venous nor arterial -Trauma -Venous insufficiency -Arterial insufficiency

Arterial insufficiency Explanation: Characteristics of arterial insufficiency ulcers include location at the tips of the toes, extreme painfulness, and circular shape with pale to black ulcer bases. Ulcers caused by venous insufficiency will be irregular in shape, minimal pain if superficial (can be painful), and usually located around the ankles or the anterior tibial area. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Peripheral Artery Disease, p. 833.

The nurse is caring for a client with heart failure. What sign will lead the nurse to suspect right-sided and left-sided heart failure?

Ascites Right-sided heart failure is characterized by signs of circulatory congestion, such as leg edema, jugular vein distention, ascites, and hepatomegaly. Left-sided heart failure is characterized by circumoral cyanosis, crackles, and a productive cough. Mixed heart failures can have all symptoms of right and left plus cool extremities, resting tachycardia, and weight gain.

A client with left-sided heart failure is in danger of impaired renal perfusion. How would the nurse assess this client for impaired renal perfusion?

Assess for elevated blood urea nitrogen levels

A client arrives at the ED with an exacerbation of left-sided heart failure and reports shortness of breath. Which is the priority nursing intervention?

Assess oxygen saturation

The client had an abdominal aortic aneurysm repair two (2) days ago. Which intervention should the nurse implement first?

Assess the client's bowel sounds.

The cardiac monitor alarm alerts the critical care nurse that the client is showing no cardiac rhythm on the monitor. The nurse's rapid assessment suggests cardiac arrest. In providing cardiac resuscitation documentation, how should the nurse describe this initial absence of cardiac rhythm?

Asystole

The triage nurse in the emergency department is assessing a client with chronic heart failure who has presented with worsening symptoms. In reviewing the client's medical history, which condition is a potential primary cause of the client's heart failure?

Atherosclerosis

You are presenting a workshop at the senior citizens center about how the changes of aging predisposes clients to vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in the older adult? a) Aneurysm b) Coronary thrombosis c) Atherosclerosis d) Raynaud's disease

Atherosclerosis Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. Therefore, options A, B, and D are incorrect.

You are presenting a workshop at the senior citizens center about how the changes of aging predisposes clients to vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in the older adult? -Aneurysm -Coronary thrombosis -Atherosclerosis -Raynaud's disease

Atherosclerosis Explanation: Atherosclerosis is the most common cause of peripheral arterial problems in the older adult. Therefore, options A, B, and D are incorrect. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Arteriosclerosis and Atherosclerosis, p. 826.

A client who is at high risk for developing intracardiac thrombi has been placed on long-term anticoagulation. Which aspect of the client's health history creates a heightened risk of intracardiac thrombi?

Atrial fibrillation

The nurse understands that a client with which cardiac arrhythmia is most at risk for developing heart failure?

Atrial fibrillation Cardiac dysrhythmias such as atrial fibrillation may either cause or result from heart failure; in both instances, the altered electrical stimulation impairs myocardial contraction and decreases the overall efficiency of myocardial function.

What is the international normalized ratio range recommended during warfarin therapy as part of the management of a patient with DVT? A. 1.5 to 2 B. 2 to 3 C. 2.5 to 3.5 D. 3 to 4

A client in the emergency department states, "I have always taken a morning walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." Based on this statement, which priority assessment should the nurse complete? Assess for unilateral swelling and tenderness of either leg. Check for the presence of tortuous veins bilaterally on the legs. Attempt to palpate the dorsalis pedis and posterior tibial pulses. Ask about any changes in skin color that occur in response to cold.

Attempt to palpate the dorsalis pedis and posterior tibial pulses.

A patient in the emergency department states, "I have always taken a morning walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." Based on this statement, which priority assessment should the nurse complete? a) Ask about any skin color changes that occur in response to cold. b) Assess for unilateral swelling and tenderness of either leg. c) Attempt to palpate the dorsalis pedis and posterior tibial pulses. d) Check for the presence of tortuous veins bilaterally on the legs.

Attempt to palpate the dorsalis pedis and posterior tibial pulses. Intermittent claudication is a sign of peripheral arterial insufficiency. The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. A thorough assessment of the patient's skin color and temperature and the character of the peripheral pulses are important in the diagnosis of arterial disorders.

A client in the emergency department states, "I have always taken a morning walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." Based on this statement, which priority assessment should the nurse complete? -Assess for unilateral swelling and tenderness of either leg. -Ask about any changes in skin color that occur in response to cold. -Attempt to palpate the dorsalis pedis and posterior tibial pulses. -Check for the presence of tortuous veins bilaterally on the legs.

Attempt to palpate the dorsalis pedis and posterior tibial pulses. Explanation: Intermittent claudication is a sign of peripheral arterial insufficiency. The nurse should assess for other clinical manifestations of peripheral arterial disease in a client who describes intermittent claudication. A thorough assessment of the client's skin color and temperature and the character of the peripheral pulses are important in the diagnosis of arterial disorders. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Diagnostic Evaluation, pp. 821-823

A nurse is checking for cardiac tamponade on a client who has pericarditis. Which of the following actions should the nurse take?

Auscultate blood pressure for pulses paradoxus

The nurse is educating a client with chronic venous insufficiency about the prevention of complications related to the disorder. What should the nurse include in the information given to the client? Select all that apply. -Avoid constricting garments. -Sit as much as possible to rest the valves in the legs. -Sleep with the foot of the bed elevated. -Elevate the legs above the heart frequently throughout the day. -Sit on the side of the bed and dangle the feet.

Avoid constricting garments. Elevate the legs above the heart frequently throughout the day. Sleep with the foot of the bed elevated. Explanation: Elevating the legs decreases edema, promotes venous return, and provides symptomatic relief. The legs should be elevated frequently throughout the day. At night, the client should sleep with the foot of the bed elevated. Prolonged sitting or standing in one position is detrimental; walking should be encouraged. When sitting, the client should avoid placing pressure on the popliteal spaces (as occurs when crossing the legs or sitting with the legs dangling over the side of the bed). Constricting garments, especially socks that are too tight at the top or leave marks on the skin, should be avoided. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Chronic Venous Insufficiency/ Postthrombotic Syndrome, p. 853.

The nurse is reviewing a newly admitted client's electronic health record, which notes a history of orthopnea. What nursing action is most clearly indicated?

Avoid positioning the client supine.

The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack? a) Avoid situations that contribute to ischemic episodes. b) Avoid fatty foods and exercise. c) Take over-the-counter decongestants. d) Report changes in the usual pattern of chest pain.

Avoid situations that contribute to ischemic episodes. Teaching for clients with Raynaud's disease and their family members is important. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants

The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack? -Avoid fatty foods and exercise. -Report changes in the usual pattern of chest pain. -Avoid situations that contribute to ischemic episodes. -Take over-the-counter decongestants.

Avoid situations that contribute to ischemic episodes. Explanation: Teaching for clients with Raynaud's disease and their family members is important. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Raynaud's Phenomenon and Other Acrosyndromes, p. 844.

The nurse is teaching a group of clients with heart failure about how to decrease leg edema. What dietary advice will the nurse give to clients with severe heart failure?

Avoid the intake of processed and commercially prepared foods.

When teaching a client with peripheral vascular disease about foot care, a nurse should include which instruction? a) Avoid wearing cotton socks. b) Avoid wearing canvas shoes. c) Avoid using a nail clipper to cut toenails. d) Avoid using cornstarch on the feet.

Avoid wearing canvas shoes. The client should be instructed to avoid wearing canvas shoes. Canvas shoes cause the feet to perspire, and perspiration can cause skin irritation and breakdown. Cotton and cornstarch absorb perspiration. The client should be instructed to cut toenails straight across with nail clippers

A positive Homans sign is present in approximately what percentage of patients with DVT? A. 25% B. 33% C. 50% D. 75%

Cilostazol should be used with great caution in the presence of: A. DM B. HF C. HTN D. dylipidemia

In ordering imaging studies in a patient with peripheral vascular disease, the use of contrast medium can potentially result in: A. hepatic failure B. renal failure C. bone marrow suppression D. thrombocytopenia

In providing care for a patient with superficial thrombophlebitis, the NP considers that: A. it is a benign, self-limiting disease. B. the linear pattern of induration can help differentiate the process from cellulitis or other inflammatory processes. C. a chest radiograph should be obtained. D. limited activity enhances recovery.

Medications that are often helpful in relieving symptoms associated with Raynaud phenomenon include: A. NSAIDs B. ACEI C. BB D. diuretics

The most common method of preventing DVT in higher risk surgical patients is the use of: A. Vitamin K B. LMWH C. vena cava filter D. warfarin

A patient is seen in the emergency department (ED) with heart failure secondary to dilated cardiomyopathy. What key diagnostic test does the nurse assess to determine the severity of the patient's heart failure?

B-type natriuretic peptide (BNP)

A client with pulmonary edema has been admitted to the ICU. What would be the standard care for this client?

BP and pulse measurements every 15 to 30 minutes

Which of the following assessment results is considered a major risk factor for PAD? -LDL of 100 mg/dL -Cholesterol of 200 mg/dL -BP of 160/110 mm Hg -Triglyceride level of 150 mg/dL

BP of 160/110 mm Hg Explanation: Hypertension is considered a major risk factor for PAD. Blood pressure should be less than 130/90 mm Hg. The other laboratory results are within the recommended range of normal to high normal. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Arteriosclerosis and Atherosclerosis, p. 828.

The nurse is caring for an older adult client who has just returned from the operating room (OR) after inguinal hernia repair. The OR report indicates that the client received large volumes of IV fluids during surgery, and the client has a history of coronary artery disease, increasing the risk for left-sided heart failure. Which signs and symptoms indicating this condition would the nurse look for?

Bibasilar fine crackles

A client with heart failure has met with the primary care provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the client begins treatment, the nurse would prioritize which assessment?

Blood Pressure

The nurse is caring for a client who is receiving a loop diuretic for the treatment of heart failure. What assessment should the nurse prioritize?

Blood pressure

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? a) Urine output of 150 ml/hour and heart rate of 45 beats/minute b) Urine output of 15 ml/hour and 2+ hematuria c) Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute d) Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute

Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute Assessment findings that indicate possible bleeding or recurring dissection include hypotension with reflex tachycardia (as evidenced by a blood pressure of 82/40 mm Hg and a heart rate of 125 beats/minute), decreased urine output, and unequal or absent peripheral pulses. Hematuria, increased urine output, and bradycardia aren't signs of bleeding from aneurysm repair or recurring dissection.

A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? -Urine output of 150 ml/hour and heart rate of 45 beats/minute -Urine output of 15 ml/hour and 2+ hematuria -Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute -Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute

Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute Explanation: Assessment findings that indicate possible bleeding or recurring dissection include hypotension with reflex tachycardia (as evidenced by a blood pressure of 82/40 mm Hg and a heart rate of 125 beats/minute), decreased urine output, and unequal or absent peripheral pulses. Hematuria, increased urine output, and bradycardia aren't signs of bleeding from aneurysm repair or recurring dissection. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Thoracic Aortic Aneurysm, p. 839.

A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless temporary change? a) Purplish stools b) Coldness of the soles c) Redness of the upper part of the feet d) Bluish urine

Bluish urine Lymphangiography may turn the urine blue temporarily; it doesn't alter stool color. For several months after the procedure, the upper part of the feet may appear blue, not red. Lymphangiography doesn't affect the soles.

Which of the following observations regarding ulcer formation on the patient's lower extremity indicates that the ulcer is a result of venous insufficiency? a) Is very painful to the patient, even though superficial b) Is deep, involving the joint space c) Border of the ulcer is irregular d) Base is pale to black

Border of the ulcer is irregular The border of an ulcer caused by arterial insufficiency is circular. Superficial venous insufficiency ulcers cause minimal pain. The base of a venous insufficiency ulcer shows beefy red to yellow fibrinous color. Venous insufficiency ulcers are usually superficial.

Which of the following is a characteristic of an arterial ulcer? a) Ankle-brachial index (ABI) > 0.90 b) Border regular and well demarcated c) Edema may be severe d) Brawny edema

Border regular and well demarcated Characteristics of an arterial ulcer include a border that is regular and demarcated. Brawny edema, ABI > 0.90, and edema that may be severe are characteristics of a venous ulcer.

Which of the following is a characteristic of an arterial ulcer? -Border regular and well demarcated -Edema may be severe -Ankle-brachial index (ABI) > 0.90 -Brawny edema

Border regular and well demarcated Explanation: Characteristics of an arterial ulcer include a border that is regular and demarcated. Brawny edema, ABI > 0.90, and edema that may be severe are characteristics of a venous ulcer. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Leg Ulcers, p. 855.

Comprehensive treatment for PAD and DM includes all of the following except: A. daily ASA use B. lipid lowering with a statin C. topical antimicrobial to affected area D. maintenance of glycemic control

Presentation of superficial venous thrombophlebitis usually includes: A. positive Homans sign. B. diminished dorsalis pedis pulse. C. a dilated vessel. D. dependent pallor.

Spider varicosities are: A. usually symptomatic. B. a potential site for thrombophlebitis. C. responsive to laser obliteration. D. caused by sun exposure.

The onset of anticoagulation effect of warfarin usually occurs how soon after the initiation of therapy? A. immediately B. 1 to 2 days C. 3 to 5 days D. 5 to 7 days

When advising a woman with varicose veins about the use of support stockings, you consider that the preferred type: A. can be purchased in the hosiery section of a department store. B. is a lightweight pair and available over-the-counter. C. is a medium-weight to heavy-weight prescription product. D. is used in the form of panty hose.

Which is the most common presentation in a patient with Raynaud phenomenon? A. digital ulceration B. worsening of symptoms in warm weather C. a period of intense itchiness after blanching D. unilateral symptoms

Which is the most potent risk factor for PVD? A. HTN B. older age C. cigarette smoking D. leg injury

Which of the following statements is most accurate in the assessment of a patient with varicose veins? A. The degree of venous tortuosity is well-correlated with the amount of leg pain reported. B. As the number of affected veins increases, so does the degree of patient discomfort. C. Symptoms are sometimes reported with minimally affected vessels. D. Lower-extremity edema is usually seen only with severe disease.

A client who has developed congestive heart failure must learn to make dietary adaptations. The client should avoid:

Canned peas There is a wide variety of foods that the client can still eat; the key is to have low-salt content. Canned vegetables are usually very high in salt or sodium, unless they have labels such as low-salt or sodium free or salt free. It is important to read food labels and look for foods that contain less than 300 mg sodium/serving

A nurse has completed a cardiovascular assessment on a client. Which of the following findings should the nurse report to the provider?

Capillary refill of 3 seconds

Diagnostic imaging reveals that the quantity of fluid in a client's pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of which complication?

Cardiac tamponade

A client has been prescribed furosemide 80 mg twice daily. The asymptomatic client begins to have rare premature ventricular contractions followed by runs of bigeminy with stable signs. What action will the nurse perform next?

Check the client's potassium level.

A patient in severe pulmonary edema is being intubated by the respiratory therapist. What priority action by the nurse will assist in the confirmation of tube placement in the proper position in the trachea?

Chest x ray

Health teaching includes advising patients on ways to reduce PAD. The nurse should always emphasize that the strongest risk factor for the development of atherosclerotic lesions is: Lack of exercise. Stress. Obesity. Cigarette smoking.

Cigarette smoking.

Health teaching includes advising patients on ways to reduce PAD. The nurse should always emphasize that the strongest risk factor for the development of atherosclerotic lesions is: -Obesity. -Cigarette smoking. -Lack of exercise. -Stress.

Cigarette smoking. Explanation: Nicotine decreases blood flow, increases heart rate and blood pressure, and increases the risk for clot formation by increasing platelet aggregation. Smokers have a four-fold higher risk of developing pain from arterial disease than nonsmokers. Carbon monoxide, produced by burning tobacco, combines with hemoglobin more readily than oxygen, thus depriving tissues of oxygen. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Arteriosclerosis and Atherosclerosis, p. 827.

The nurse is caring for a client in the hospital with chronic heart failure that has marked limitations in his physical activity. The client is comfortable when resting in the bed or chair, but when ambulating in the room or hall, he becomes short of breath and fatigued easily. What type of heart failure is this considered according to the New York Heart Association (NYHA)?

Class III Class III (Moderate) is when there is marked limitation of physical activity. The client is comfortable at rest, but less than ordinary activity causes fatigue, heart palpitations, or dyspnea. Class I is ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea. The client does not experience any limitation of activity. Class II (Mild) is when the client is comfortable at rest, but ordinary physical activity results in fatigue, heart palpitations, or dyspnea. Class IV (Severe), the client is unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency occur at rest. Discomfort is increased if any physical activity is undertaken.

Pentoxifylline (Trental) is a medication used for which of the following conditions? Elevated triglycerides Hypertension Claudication Thromboemboli

Claudication

Pentoxifylline (Trental) is a medication used for which of the following conditions? a) Claudication b) Elevated triglycerides c) Hypertension d) Thromboemboli

Claudication Trental and Pletal are the only medications specifically indicated for the treatment of claudication. Thromboemboli, hypertension, and elevated triglycerides are not indications for using Trental.

A nurse is caring for a client who had a myocardial infarction 5 days ago. The client has a sudden onset of shortness of breath and begins coughing frothy, pink sputum. The nurse auscultates loud, bubbly sounds on inspiration. Which of the following adventitious breath sounds should the nurse document?

Coarse crackles

The nurse is caring for a client with systolic heart failure whose previous adverse reactions rule out the safe use of angiotensin-converting enzyme (ACE) inhibitors. The nurse should anticipate that the prescriber may choose which combination of drugs?

Combination of hydralazine and isosorbide dinitrate

The nurse assesses a patient with hip pain related to intermittent claudication. She knows that the area of arterial narrowing is the: Common iliac artery. Common femoral artery. Anterior tibial. Posterior tibial.

Common iliac artery.

The nurse assesses a patient with hip pain related to intermittent claudication. She knows that the area of arterial narrowing is the: -Anterior tibial. -Common femoral artery. -Posterior tibial. -Common iliac artery.

Common iliac artery. Explanation: The location of the claudication occurs in muscle groups distal to the diseased vessel. Hip or buttock pain may result from reduced blood flow from the common iliac artery. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Arteriosclerosis and Atherosclerosis, p. 826.

The client is admitted for surgical repair of an 8-cm abdominal aortic aneurysm (AAA). Which sign/symptom would make the nurse suspect the client has an expanding AAA?

Complaints of low back pain

The nurse is caring for a client recovering from acute axillary lymphangitis. Which treatment will the nurse anticipate being prescribed for this client after antibiotic therapy has concluded? Arm sling Compression sleeve Physical therapy Aspirin therapy

Compression sleeve

The nurse is caring for a client recovering from acute axillary lymphangitis. Which treatment will the nurse anticipate being prescribed for this client after antibiotic therapy has concluded? -Aspirin therapy -Compression sleeve -Physical therapy -Arm sling

Compression sleeve Explanation: Lymphangitis is an acute inflammation of the lymphatic channels. It arises most commonly from a focal area of infection in an extremity caused by bacteria. At the conclusion of antibiotic therapy used for an acute attack, a graduated compression sleeve should be worn on the affected extremity for several months to prevent long-term edema. An arm sling is not required. The client will not need aspirin therapy as there is no surgery and/or risk of clots. The client will not need physical therapy as there should be no lingering effects from treatment of lymphangitis. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Lymphangitis and Lymphadenitis, p. 860.

A health care provider wants a cross-sectional image of the abdomen to evaluate the degree of stenosis in a patient's left common iliac artery. The nurse knows to prepare the patient for which of the following? -Computed tomography angiography (CTA) -Angiography -Doppler ultrasound -Magnetic resonance angiography (MRA)

Computed tomography angiography (CTA) Explanation: A CTA is used to visualize arteries and veins and help assess for stenosis and occlusion. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Diagnostic Evaluation, p. 825.

The nurse is caring for an adult client with heart failure who is prescribed digoxin. When assessing the client for adverse effects, the nurse should assess for which of the following signs and symptoms? Select all that apply.

Confusion Bradycardia

Which of the following are indications of a rupturing aortic aneurysm? Select all that apply. -Constant, intense back pain -Increasing blood pressure -Increasing hematocrit -Decreasing hematocrit -Decreasing blood pressure

Constant, intense back pain Decreasing blood pressure Decreasing hematocrit Explanation: Indications of a rupturing abdominal aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Abdominal Aortic Aneurysm, p. 840.

A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following? Higher than normal blood pressure and falling hematocrit Slow heart rate and high blood pressure Constant, intense back pain and falling blood pressure Constant, intense headache and falling blood pressure

Constant, intense back pain and falling blood pressure

A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following? a) Slow heart rate and high blood pressure b) Constant, intense back pain and falling blood pressure c) Higher than normal blood pressure and falling hematocrit d) Constant, intense headache and falling blood pressure

Constant, intense back pain and falling blood pressure Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit.

A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following? -Constant, intense headache and falling blood pressure -Constant, intense back pain and falling blood pressure -Higher than normal blood pressure and falling hematocrit -Slow heart rate and high blood pressure

Constant, intense back pain and falling blood pressure Explanation: Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Abdominal Aortic Aneurysm, p. 840.

The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is which of the following? a) Lymphoscintigraphy b) Contrast phlebography c) Lymphangiography d) Air plethysmography

Contrast phlebography Also known as venography, contrast phlebography involves injecting a radiopaque contrast agent into the venous system. If a thrombus exists, the x-ray image reveals an unfilled segment of vein in an otherwise completely filled vein. Air plethysmography quantifies venous reflux and calf muscle pump ejection. In lymphangiography, contrast media are injected into the lymph system. In a lymphoscintigraphy, a radioactive-labeled colloid is injected into the lymph system.

Which of the following is a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot? a) Lymphoscintigraphy b) Lymphangiography c) Contrast phlebography d) Air plethysmography

Contrast phlebography When a thrombus exists, an X-ray image will disclose an unfilled segment of a vein. Air plethysmography quantifies venous reflux and calf muscle pump ejection. In lymphangiography, contrast media are injected into the lymph system. In lymphoscintigraphy, a radioactive-labeled colloid is injected into the lymph system.

The nurse is assessing a patient with suspected acute venous insufficiency. What clinical manifestations would indicate this condition to the nurse? (Select all that apply.) -Full superficial veins -Initial absence of edema -Cool and cyanotic skin -Sharp pain that may be relieved by the elevation of the extremity -Brisk capillary refill of the toes

Cool and cyanotic skin Sharp pain that may be relieved by the elevation of the extremity Full superficial veins Postthrombotic syndrome is characterized by chronic venous stasis, resulting in edema, altered pigmentation, pain, and stasis dermatitis. The patient may notice the symptoms less in the morning and more in the evening. Obstruction or poor calf muscle pumping in addition to valvular reflux must be present for the development of severe postthrombotic syndrome and stasis ulcers. Superficial veins may be dilated. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Peripheral Artery Disease, p. 835.

A nurse in a clinic is collecting data from a client who has a history of peripheral arterial disease. Which of the following findings on the clients lower extremities should the nurse expect?

Cool, pale skin with minimal body hair

A nurse is preparing to conduct a cardiovascular assessment on a client. Which of the following actions should the nurse plan to take? (SATA)

Correct terms: -auscultate the apical pulse -ask the client if they experience shortness of breath -check the color of the client's skin -Inspect the extremities for the presence of edema

A nurse is caring for a client who has a peripheral venous ulcer. Which of the following actions should the nurse take? (SATA)

Correct terms: -instruct the client to sit with their legs uncrossed. -encourage the client to avoid tobacco products. -instruct the client to cleanse the area with mild soap. -instruct the client to wear shoes when ambulating.

Clinical presentation of advanced PVD includes all of the following except: A. resting pain B. absent posterior tibialis pulse C. blanching of foot with elevation D. spider varicosities

Drug therapy that had previously thought to worsen symptoms in lower extremity PAD includes the use of: A. Beta2- adrenergic blockers B. CCB C. direct thrombin inhibitors D. beta-adrenergic blockers

In patients with varicose veins, which vessel is most often affected? A. femoral vein B. posterior tibial vein C. peroneal vein D. saphenous vein

The anticipated result of debridement as part of the treatment of venous stasis ulcers includes all of the following except: A. enhanced tissue granulation B. encouragement of reepitheliaziation C. reduction of bacterial burden D. prevention of peripheral arterial disease

The initial diagnostic evaluation of a clinically stable patient with suspected DVT most often includes obtaining a/an: A. impedance plethysmography. B. iodine 125 fibrinogen scan. C. contrast venography. D. duplex ultrasonography.

Treatment options for venous stasis ulcers in the lower extremities include: A. cleansing with hydrogen peroxide B. applying Burrow solution C. prescribing a systemic corticosteroid D. applying a moisture retaining dressing

Which of the following does not directly contribute to the development of varicose veins? A. leg crossing B. pregnancy C. heredity D. Raynaud disease

Which of the following is least likely to be found in patients with pulmonary embolus (PE)? A. pleuritic chest pain B. tachypnea C. DVT signs and symptoms D. hemoptysis

Which of the following is not a contributing factor to development of venous thrombophlebitis? A. venous status B. injury to vascular intima C. malignancy-associated hypercoagulation states D. isometric exercise

Who is most likely to have new onset primary Raynaud phenomenon? A. a 68 yo man B. a 65 yo woman C. a 25 yo man D. an 18 yo woman

A nurse is auscultating heart sounds. Identify the location where the apical pulse is auscultated.

D is correct.

As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client? Assess for skin integrity. Demonstrate how to self-administer IV infusions. Assess for the sites of bleeding. Demonstrate how to apply and remove elastic support stockings.

Demonstrate how to apply and remove elastic support stockings.

A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect?

Dependent edema

A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client?

Development of left sided heart failure When the left ventricle fails, the heart muscle cannot contract forcefully enough to expel blood into the systemic circulation. Blood subsequently becomes congested in the left ventricle, left atrium, and finally the pulmonary vasculature. Symptoms of left-sided failure include fatigue; paroxysmal nocturnal dyspnea; orthopnea; hypoxia; crackles; cyanosis; S3 heart sound; cough with pink, frothy sputum; and elevated pulmonary capillary wedge pressure. COPD develops over many years and does not develop after a myocardial infarction. The development of right-sided heart failure would generally occur after a right ventricle myocardial infarction or after the development of left-sided heart failure. Cor pulmonale is a condition in which the heart is affected secondarily by lung damage.

Which medication reverses digitalis toxicity?

Digoxin immune FAB

Which of the following are characteristics of arterial insufficiency? a) Diminished or absent pulses b) Pulses are present, may be difficult to palpate c) Aching, cramping pain d) Superficial ulcer

Diminished or absent pulses A diminished or absent pulse is a characteristic of arterial insufficiency. Venous characteristics include superficial ulcer formation, an aching and cramping pain, and presence of pulses

The nurse performing an assessment on a patient who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which of the following characteristics? a) Superficial ulcer b) Aching, cramping pain c) Diminished or absent pulses d) Pulses are present, may be difficult to palpate

Diminished or absent pulses Occlusive arterial disease impairs blood flow and can reduce or obliterate palpable pulsations in the extremities. A diminished or absent pulse is a characteristic of arterial insufficiency

The nurse assessing a client who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which characteristic? -Aching, cramping pain -Diminished or absent pulses -Pulses that are present but difficult to palpate -Superficial ulcer

Diminished or absent pulses Explanation: Occlusive arterial disease impairs blood flow and can reduce or obliterate palpable pulsations in the extremities. A diminished or absent pulse is a characteristic of arterial insufficiency. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Pathophysiology of the Vascular System, p. 821.

The nurse assessing a client who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which characteristic? Diminished or absent pulses Aching, cramping pain Superficial ulcer Pulses that are present but difficult to palpate

Diminished or absent pulsesp

A nurse is assessing a client who reports an increase in their stress level related to the demands of their job. Which of the following interventions should the nurse recommend for the client to reduce their stress?

Discuss the benefits of meditation with the client.

Which aneurysm results in bleeding into the layers of the arterial wall? Anastomotic Dissecting False Saccular

Dissecting

Which of the following aneurysms results in bleeding into the layers of the arterial wall? a) Anastomotic b) Dissecting c) False d) Saccular

Dissecting Dissection results from a rupture in the intimal layer, resulting in bleeding between the intimal and medial layers of the arterial wall. Saccular aneurysms collect blood in the weakened outpouching. In a false aneurysm, the mass is actually a pulsating hematoma. An anastomotic aneurysm occurs as a result of infection at arterial suture or graft sites. (less)

Which aneurysm results in bleeding into the layers of the arterial wall? -False -Anastomotic -Saccular -Dissecting

Dissecting Explanation: Dissection results from a rupture in the intimal layer, resulting in bleeding between the intimal and medial layers of the arterial wall. Saccular aneurysms collect blood in the weakened outpouching. In a false aneurysm, the mass is actually a pulsating hematoma. An anastomotic aneurysm occurs as a result of infection at arterial suture or graft sites. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Aortoiliac Disease, p. 838.

The nurse is assessing a client who is known to have right-sided heart failure. What assessment finding is most consistent with this client's diagnosis?

Distended neck veins

The nurse assessing a client with an exacerbation of heart failure identifies which symptom as a cerebrovascular manifestation of heart failure (HF)?

Dizziness

The nurse is assessing a client admitted with cardiogenic shock. What medication will the nurse titrate to improve blood flow to vital organs?

Dopamine Dopamine, a sympathomimetic drug, is used to treat cardiogenic shock. It increases perfusion pressure to improve myocardial contractility and blood flow through vital organs. Enalapril is an angiotensin-converting enzyme inhibitor that directly lowers blood pressure. Furosemide is a diuretic and doesn't have a direct effect on contractility or tissue perfusion. Metoprolol is a beta-adrenergic blocker that slows heart rate and lowers blood pressure, undesirable effects when treating cardiogenic shock.

A patient who had a colon resection 3 days ago is complaining of discomfort in the left calf. How should the nurse assess Homan's sign to determine if the patient may have a thrombus formation in the leg? Lower the patient's legs and massage the calf muscles to note any areas of tenderness. Dorsiflex the foot while the leg is elevated to check for calf pain. Elevate the patient's legs for 20 minutes and then lower them slowly while checking for areas of inadequate blood return. Extend the leg, plantar flex the foot, and check for the patency of the dorsalis pedis pulse.

Dorsiflex the foot while the leg is elevated to check for calf pain.

A patient who had a colon resection 3 days ago is complaining of discomfort in the left calf. How should the nurse assess Homan's sign to determine if the patient may have a thrombus formation in the leg? -Lower the patient's legs and massage the calf muscles to note any areas of tenderness. -Dorsiflex the foot while the leg is elevated to check for calf pain. -Extend the leg, plantar flex the foot, and check for the patency of the dorsalis pedis pulse. -Elevate the patient's legs for 20 minutes and then lower them slowly while checking for areas of inadequate blood return.

Dorsiflex the foot while the leg is elevated to check for calf pain. Explanation: Homan's sign is indicated by pain in the calf after the foot is sharply dorsiflexed. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Deep Vein Thrombosis, p. 847.

The nurse knows which of the following diagnostic tests are used to document the anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux? a) Duplex ultrasound scan b) Contrast phlebography c) Lymphoscintigraphy d) Lymphangiography

Duplex ultrasound scan Diagnostic tests for varicose veins include the duplex ultrasound scan, which documents the anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux. Contrast phlebography involves injecting a radiopaque contrast agent into the venous system. Lymphoscintigraphy is done when a radioactively labeled colloid is injected subcutaneously in the second interdigital space. The extremity is then exercised to facilitate the uptake of the colloid by the lymphatic system, and serial images are obtained at present intervals. Lymphoangiography provides a way of detecting lymph node involvement resulting from metastatic carcinoma, lymphoma, or infection in sites that are otherwise inaccessible to the examiner except by surgery.

The nurse is preparing a teaching tool about the development of a venous thromboembolism. Which information about Virchow triad will the nurse include? Select all that apply. Altered coagulation Prominent veins Edematous extremity Endothelial damage Venous stasis

Endothelial damage, Altered coagulation, Venous stasis

A nurse is caring for a client who has advanced heart failure. Which of the following actions should the nurse take?

Enforce fluid restrictions

The nurse knows which diagnostic test is used to document the anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux? -Duplex ultrasound scan -Contrast phlebography -Lymphoscintigraphy -Lymphangiography

Duplex ultrasound scan Explanation: Diagnostic tests for varicose veins include the duplex ultrasound scan, which documents the anatomic site of reflux and provides a quantitative measure of the severity of valvular reflux. Contrast phlebography involves injecting a radiopaque contrast agent into the venous system. Lymphoscintigraphy is done when a radioactively labeled colloid is injected subcutaneously in the second interdigital space. The extremity is then exercised to facilitate the uptake of the colloid by the lymphatic system, and serial images are obtained at preset intervals. Lymphangiography provides a way to detect lymph node involvement resulting from metastatic carcinoma, lymphoma, or infection in sites that are otherwise inaccessible to the examiner except by surgery. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Duplex Ultrasonography, p. 825.

A nurse is collecting data from a client who has pericarditis. Which of the following manifestations should the nurse expect?

Dyspnea

The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure?

Dyspnea on exertion

A client has been having cardiac symptoms for several months and is seeing a cardiologist for diagnostics to determine the cause. How will the client's ejection fraction be measured?

Echocardiogram

The nurse is teaching a client with heart failure about the ability for the heart to pump out blood. What diagnostic test will measure the ejection fraction of the heart?

Echocardiogram

A client with a diagnosis of heart failure is started on a beta-blocker. What is the nurse's priority role during gradual increases in the client's dose?

Educating the client that symptom relief may not occur for several weeks

The nurse is caring for a client with a history of heart failure and a sudden onset of tachypnea. What is the nurse's priority action?

Elevate the head of the bed

A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency? Avoid foods with iodine. Elevate the legs periodically for at least an hour. Refrain from sexual activity for a week. Elevate the legs periodically for at least 15 to 20 minutes.

Elevate the legs periodically for at least 15 to 20 minutes.

A nurse is checking laboratory values for an adult client who has sickle cell anemia and is in crisis. For which of the following complications should the nurse monitor?

Elevated bilirubin

A client with peripheral artery disease (PAD) has limited access to supervised exercise therapy (SET). Which recommendation will the nurse make to help the client's intermittent claudication? Engage in an unsupervised walking program. Sleep with the legs in a horizontal position. Take an aspirin before going to bed at night. Elevate the lower extremities several times during the day.

Engage in an unsupervised walking program.

A client with peripheral artery disease (PAD) has limited access to supervised exercise therapy (SET). Which recommendation will the nurse make to help the client's intermittent claudication? -Engage in an unsupervised walking program. -Take an aspirin before going to bed at night. -Elevate the lower extremities several times during the day. -Sleep with the legs in a horizontal position.

Engage in an unsupervised walking program. Explanation: Generally, clients feel better and have fewer symptoms of claudication after participating in a SET program. However unsupervised walking exercise programs are attractive for many clients with PAD with limited access to a SET program. Based upon research studies, home-based programs may be a viable and efficacious option for clients unable to participate in a structured, on-site, supervised exercise program. Sleeping with the legs in a horizontal position increases the pain. The health care provider will prescribe medications appropriate for the client. It is beyond the nurse's scope of practice to recommend a medication. Elevating the lower extremities increases the pain. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Arteriosclerosis and Atherosclerosis, p. 831.

A patient is having an angiography to detect the presence of an aneurysm. After the contrast is administered by the interventionist, the patient begins to complain of nausea and difficulty breathing. What medication is a priority to administer at this time? Metoprolol (Lopressor) Hydrocortisone (Solu-Cortef) Cimetidine (Tagamet) Epinephrine

Epinephrine

A patient is having an angiography to detect the presence of an aneurysm. After the contrast is administered by the interventionist, the patient begins to complain of nausea and difficulty breathing. What medication is a priority to administer at this time? -Epinephrine -Cimetidine (Tagamet) -Metoprolol (Lopressor) -Hydrocortisone (Solu-Cortef) SUBMIT ANSWER

Epinephrine Explanation: Infrequently, a patient may have an immediate or delayed allergic reaction to the iodine contained in the contrast agent used in angiography. Manifestations include dyspnea, nausea and vomiting, sweating, tachycardia, and numbness of the extremities. Any such reaction must be reported to the interventionalist at once; treatment may include the administration of epinephrine, antihistamines, or corticosteroids. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Diagnostic Evaluation, p. 826.

Which of the following statements is accurate regarding Reynaud's disease? a) It affects more than two digits on each hand or foot. b) Episodes may be triggered by unusual sensitivity to cold. c) The disease generally affects the patient bilaterally. d) It is most common in men 16 to 40 years of age.

Episodes may be triggered by unusual sensitivity to cold. Episodes of Reynaud's disease may be triggered by emotional factors or by unusual sensitivity to cold. The disease is most common in women between 16 and 40 years of age. It is generally unilateral and affects only one or two digits.

Which statement is accurate regarding Raynaud disease? The disease generally affects the client trilaterally. It is most common in men 16 to 40 years of age. Episodes may be triggered by unusual sensitivity to cold. It affects more than two digits on each hand or foot.

Which of the following is accurate regarding Raynaud's disease? a) It affects more than two digits on each hand or foot. b) It is generally bilateral. c) Episodes may be triggered by unusual sensitivity to cold. d) It is most common in men aged 16 to 40 years.

Episodes may be triggered by unusual sensitivity to cold. Episodes of Raynaud's disease may be triggered by emotional factors or by unusual sensitivity to cold. The disease is most common in women between the ages of 16 and 40. It is generally unilateral and affects only one or two digits.

Which statement is accurate regarding Raynaud disease? -It affects more than two digits on each hand or foot. -It is most common in men 16 to 40 years of age. -The disease generally affects the client trilaterally. -Episodes may be triggered by unusual sensitivity to cold.

Episodes may be triggered by unusual sensitivity to cold. Explanation: Episodes of Raynaud disease may be triggered by emotional factors or by unusual sensitivity to cold. The disease is most common in women between 16 and 40 years of age. It is generally unilateral and affects only one or two digits. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Raynaud's Phenomenon and Other Acrosyndromes, p. 844.

A client has a significant history of congestive heart failure. What should the nurse specifically assess during the client's semiannual cardiology examination? Select all that apply.

Examine the client's neck for distended veins. Monitor the client for signs of lethargy or confusion.

A client with acute pericarditis is exhibiting distended jugular veins, tachycardia, tachypnea, and muffled heart sounds. The nurse recognizes these as symptoms of what occurrence?

Excess pericardial fluid compresses the heart and prevents adequate diastolic filling. The cardinal signs of cardiac tamponade are falling systolic blood pressure, narrowing pulse pressure, rising venous pressure (increased JVD), and distant (muffled) heart sounds. Increased pericardial pressure, reduced venous return to the heart, and decreased carbon dioxide result in cardiac tamponade (e.g., compression of the heart).

An abnormally elevated D-Dimer is highly sensitive and specific for VTE.

FALSE

With the use of direct thrombin inhibitor, ongoing INR monitoring is not required.

FALSE

The nurse is creating a care plan for a client diagnosed with heart failure. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply.

Facilitate the presence of friends and family whenever possible. Provide supplemental oxygen, as needed. Provide validation of the client's expressions of anxiety.

An older adult client with heart failure is being discharged home on an ACE inhibitor and a loop diuretic. The client's most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this client's subsequent care, what nursing concern should be identified?

Falls risk related to hypotension

The triage nurse in the emergency department is performing a rapid assessment of a client with reports of severe chest pain and shortness of breath. The client is diaphoretic, pale, and weak. When the client collapses, which action would the nurse take first?

Gently shake and shout, "Are you OK?"

which class of medication lyses and dissolves thrombi? Fibrinolytic Platelet inhibitors Factor XA inhibitors Anticoagulant

Fibrinolytic

Which of the following medication classifications lyses and dissolves thrombi? a) Factor XA inhibitors b) Anticoagulant c) Platelet inhibitors d) Fibrinolytic

Fibrinolytic Thrombolytic (fibrinolytic) therapy lyses and dissolves thrombi in 50% of patients. Anticoagulants, platelet inhibitors, and factor XA inhibitors do no lyse or dissolve thrombi.

Which class of medication lyses and dissolves thrombi? -Platelet inhibitors -Fibrinolytic -Factor XA inhibitors -Anticoagulant

Fibrinolytic Explanation: Thrombolytic (fibrinolytic) therapy lyses and dissolves thrombi in 50% of clients. Anticoagulants, platelet inhibitors, and factor XA inhibitors do not lyse or dissolve thrombi. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Monitoring Thrombolytic Therapy, p. 852.

A client with lower extremity edema is diagnosed with lymphedema. For which medication will the nurse prepare teaching for this client? Amoxicillin Heparin Oxycodone Furosemide

Furosemide

A client with lower extremity edema is diagnosed with lymphedema. For which medication will the nurse prepare teaching for this client? -Furosemide -Heparin -Amoxicillin -Oxycodone

Furosemide Explanation: Lymphedema may be primary (congenital malformations) or secondary (acquired obstructions). Tissue swelling occurs in the extremities because of an increased quantity of lymph that results from obstruction of lymphatic vessels. As initial therapy, the diuretic furosemide may be prescribed to prevent fluid overload due to mobilization of extracellular fluid. Opioids are not used to treat lymphedema. Antibiotics would be prescribed only if an infection is present. Anticoagulants are not used to treat lymphedema. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, LYMPHATIC DISORDERS, p. 861.

A nurse is reinforcing teaching with a client who has anemia and a new prescription for epoetin alfa. Which of the following information should the nurse include in the teaching?

Hypertension is a common adverse effect of this medication

The nurse is caring for a client with suspected right-sided heart failure. What would the nurse know that clients with suspected right-sided heart failure may experience?

Gradual unexplained weight gain Clients with right-sided heart failure may have a history of gradual, unexplained weight gain from fluid retention. Left-sided heart failure produces paroxysmal nocturnal dyspnea, which may prompt the client to use several pillows in bed or to sleep in a chair or recliner. Right-sided heart failure does not cause increased perspiration or increased urine output.

A nurse is assessing a client's jugular veins and carotid arteries. The nurse should assist the client into which of the following positions?

Have the client lay supine with the head of their bed at a 45 degree angle.

A client with congestive heart failure is admitted to the hospital after reporting shortness of breath. How should the nurse position the client in order to decrease preload?

Head of the bed elevated 45 degrees and lower arms supported by pillows

A nurse is caring for a client experiencing dyspnea, dependent edema, hepatomegaly, crackles, and jugular vein distention. What condition should the nurse suspect?

Heart failure

The nurse is caring for a client with advanced heart failure. What treatment will be considered after all other therapies have failed?

Heart transplant

Providing postoperative care to a patient who has percutaneous transluminal angioplasty (PTA), with insertion of a stent, for a femoral artery lesion, includes assessment for the most serious complication of: Hemorrhage. Stent dislodgement. Decreased motor function. Thrombosis of the graft.

Hemorrhage.

A client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of thromboembolism? a) Homans' b) Phalen's c) Rinne d) Romberg's

Homans' A positive Homans' sign, or pain in the calf elicited upon flexion of the ankle with the leg straight, indicates the presence of a thrombus. Testing for Romberg's sign assesses cerebellar function. Phalen's test assesses carpal tunnel syndrome. The Rinne test compares air and bone conduction in both ears to screen for or confirm hearing loss.

A patient with diabetes is being treated for a wound on the lower extremity that has been present for 30 days. What option for treatment is available to increase diffusion of oxygen to the hypoxic wound? Enzymatic debridement Hyperbaric oxygen Vacuum-assisted closure device Surgical debridement

Hyperbaric oxygen

A patient with diabetes is being treated for a wound on the lower extremity that has been present for 30 days. What option for treatment is available to increase diffusion of oxygen to the hypoxic wound? Hyperbaric oxygen Vacuum-assisted closure device Enzymatic debridement Surgical debridement

Hyperbaric oxygen

A patient with diabetes is being treated for a wound on the lower extremity that has been present for 30 days. What option for treatment is available to increase diffusion of oxygen to the hypoxic wound? -Vacuum-assisted closure device -Surgical debridement -Hyperbaric oxygen -Enzymatic debridement

Hyperbaric oxygen Explanation: Hyperbaric oxygenation (HBO) may be beneficial as an adjunct treatment in patients with diabetes with no signs of wound healing after 30 days of standard wound treatment. HBO is accomplished by placing the patient into a chamber that increases barometric pressure while the patient is breathing 100% oxygen. Treatment regimens vary from 90 to 120 minutes once daily for 30 to 90 sessions. The process by which HBO is thought to work involves several factors. The edema in the wound area is decreased because high oxygen tension facilitates vasoconstriction and enhances the ability of leukocytes to phagocytize and kill bacteria. In addition, HBO is thought to increase diffusion of oxygen to the hypoxic wound, thereby enhancing epithelial migration and improving collagen production. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Leg Ulcers, p. 857.

The nurse is assessing a patient who reports no symptoms of heart failure at rest but is symptomatic with increased physical activity. Under what classification does the nurse understand this patient would be categorized?

II Classification II of heart failure is indicated by the patient being comfortable at rest, but experiencing fatigue, palpitation, or dyspnea during ordinary physical activity.

Which New York Heart Association classification of heart failure has a poor prognosis and includes symptoms of cardiac insufficiency at rest?

IV Symptoms of cardiac insufficiency at rest are classified as IV, according to the New York Heart Association Classification of Heart Failure. In class I, ordinary activity does not cause undue fatigue, dyspnea, palpitations, or chest pain. In class II, ADLs are slightly limited. In class III, ADLs are markedly limited.

The nurse is planning the care of a client with heart failure. The nurse should identify what overall goals of this client's care? Select all that apply.

Improve functional status Extend survival. Relieve client symptoms.

The nurse is caring for a patient who has started anticoagulant therapy with warfarin (Coumadin). When does the nurse understand that therapeutic benefits will begin? -Within the first 24 hours -In 3 to 5 days -In 2 days -Within 12 hours

In 3 to 5 days Explanation: Oral anticoagulants, such as warfarin, are monitored by the PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0) (Holbrook et al., 2012). Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Deep Vein Thrombosis, p. 848.

A client admitted to the medical unit with heart failure is exhibiting signs and symptoms of pulmonary edema. How should the nurse best position the client?

In a high Fowler position

A client is recovering from sclerotherapy to treat varicose veins. Which information will the nurse provide to the client after the procedure? Select all that apply. Increase the amount of time walking at home. Take acetaminophen as prescribed for pain. Expect a burning sensation in the injected areas for 1 to 2 days. Wear graduated compression stockings for a week after the procedure. Change the dressings once a day.

Increase the amount of time walking at home. Take acetaminophen as prescribed for pain. Expect a burning sensation in the injected areas for 1 to 2 days. Wear graduated compression stockings for a week after the procedure.

Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending? Increased abdominal and back pain Decreased pulse rate and blood pressure Retrosternal back pain radiating to the left arm Elevated blood pressure and rapid respirations

Increased abdominal and back pain

Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending? a) Elevated blood pressure and rapid respirations b) Decreased pulse rate and blood pressure c) Increased abdominal and back pain d) Retrosternal back pain radiating to the left arm

Increased abdominal and back pain Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be affected.

Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending? a) Elevated blood pressure and rapid respirations b) Retrosternal back pain radiating to the left arm c) Decreased pulse rate and blood pressure d) Increased abdominal and back pain

A nurse is teaching a patient newly diagnosed with arterial insufficiency. Which of the following terms should the nurse use to refer to leg pain that occurs when the patient is walking? a) Dyspnea b) Thromboangiitis obliterans c) Orthopnea d) Intermittent claudication

Intermittent claudication Intermittent claudication is leg pain that is brought on by exercise and relieved by rest. Dyspnea is the patient's subjective statement of difficulty breathing. Orthopnea is the inability of the patient to breathe except in the upright (sitting) position. Thromboangiitis obliterans is a peripheral vascular disease also known as Buerger's disease. (less)

Which sign or symptom suggests that a client's abdominal aortic aneurysm is extending? -Elevated blood pressure and rapid respirations -Retrosternal back pain radiating to the left arm -Increased abdominal and back pain -Decreased pulse rate and blood pressure

Increased abdominal and back pain Explanation: Pain in the abdomen and back signify that the aneurysm is pressing downward on the lumbar nerve root and is causing more pain. The pulse rate would increase with aneurysm extension. Chest pain radiating down the arm would indicate myocardial infarction. Blood pressure would decrease with aneurysm extension, and the respiratory rate may not be affected. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Pathophysiology, p. 845.

A nurse is developing a nursing care plan for a client with peripheral arterial disease. Which of the following will be the priority nursing diagnosis? -Impaired tissue integrity -Ineffective self-health management -Ineffective thermoregulation -Ineffective peripheral tissue perfusion

Ineffective peripheral tissue perfusion Explanation: The goal is to increase arterial blood supply to the extremities; the priority nursing diagnosis is Ineffective peripheral tissue perfusion related to compromised circulation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Arteriosclerosis and Atherosclerosis, p. 830.

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? a) Excess fluid volume related to peripheral vascular disease b) Risk for injury related to edema c) Ineffective peripheral tissue perfusion related to venous congestion d) Impaired gas exchange related to increased blood flow

Ineffective peripheral tissue perfusion related to venous congestion Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with DVT. Impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Excess fluid volume related to peripheral vascular disease is inappropriate because there's no evidence that this client has an excess fluid volume. Risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion.

Which of the following terms refers to leg pain that is brought on walking and caused by arterial insufficiency? a) Thromboangiitis obliterans b) Intermittent claudication c) Orthopnea d) Dyspnea

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? -Impaired gas exchange related to increased blood flow -Ineffective peripheral tissue perfusion related to venous congestion -Risk for injury related to edema -Excess fluid volume related to peripheral vascular disease

Ineffective peripheral tissue perfusion related to venous congestion Explanation: Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with DVT. Impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Excess fluid volume related to peripheral vascular disease is inappropriate because there's no evidence that this client has an excess fluid volume. Risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Deep Vein Thrombosis, p. 846

A nurse is assisting in the plan of care for a client who is having a percutaneous transluminal coronary angioplasty (PTCA) with stent placement. Which of the following actions should the nurse anticipate in the postoperative plan of care?

Initiate an aspirin regimen

A nurse is contributing to the plan of care for a client who has pernicious anemia. Which of the following interventions should the nurse recommend?

Initiate weekly injections of vitamin B12

The nurse is caring for a client with severe left ventricular dysfunction who has been identified as being at risk for sudden cardiac death. Which medical intervention can be performed that may extend the survival of the client?

Insertion of an implantable cardioverter defibrillator (ICD)

Which of the following terms refers to a muscular, cramplike pain in the extremities consistently reproduced with the same degree of exercise and relieved by rest? a) Aneurysm b) Intermittent claudication c) Ischemia d) Bruit

Intermittent claudication Intermittent claudication is a sign of peripheral arterial insufficiency. An aneurysm is a localized sac of an artery wall formed at a weak point in the vessel. A bruit is the sound produced by turbulent blood flow through an irregular, tortuous, stenotic, or dilated vessel. Ischemia is a term used to denote deficient blood supply.

Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity? a) Intermittent claudication b) Acute limb ischemia c) Dizziness d) Vertigo

Intermittent claudication The hallmark symptom of PAD in the lower extremity is intermittent claudication. This pain may be described as aching or cramping in a muscle that occurs with the same degree of exercise or activity and is relieved with rest. Acute limb ischemia is a sudden decrease in limb perfusion, which produces new or worsening symptoms that may threaten limb viability. Dizziness and vertigo are associated with upper extremity arterial occlusive disease.

Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity? -Acute limb ischemia -Dizziness -Intermittent claudication -Vertigo

Intermittent claudication Explanation: The hallmark symptom of PAD in the lower extremity is intermittent claudication. This pain may be described as aching or cramping in a muscle that occurs with the same degree of exercise or activity and is relieved with rest. Acute limb ischemia is a sudden decrease in limb perfusion, which produces new or worsening symptoms that may threaten limb viability. Dizziness and vertigo are associated with upper extremity arterial occlusive disease. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Peripheral Artery Disease, p. 835.

A client is receiving enoxaparin and warfarin therapy for a venous thromboembolism (VTE). Which laboratory value indicates that anticoagulation is adequate and enoxaparin can be discontinued? -K+ level is 3.5. -Activated partial thromboplastin time (aPPT) is half of the control value -Prothrombin time (PT) is 0.5 times normal. -International normalized ratio (INR) is 2.5.

International normalized ratio (INR) is 2.5. Explanation: Oral anticoagulants such as warfarin are monitored by PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (i.e., when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0) Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Deep Vein Thrombosis, pp. 846-848.

A nurse is assessing a client with congestive heart failure for jugular vein distension (JVD). Which observation is important to report to the physician?

JVD is noted 4 cm above the sternal angle. JVD is assessed with the client sitting at a 45° angle. Jugular vein distention greater than 4 cm above the sternal angle is considered abnormal and is indicative of right ventricular failure

A nurse is collecting data from a client who has fluid volume overload resulting from a cardiovascular disorder. Which of the following manifestations should the nurse expect? (select all that apply)

Jugular vein distension Moist crackles Increased heart rate

Which is a characteristic of right-sided heart failure?

Jugular vein distention

The nurse plans care for a client who is newly diagnosed with peripheral artery disease (PAD). For each nursing action, choose which intervention is appropriate, to increase the arterial blood supply to the client's extremities or to promote vasodilation and prevent vascular compression. Keep legs in a dependent position.(Increase arterial blood supply to the extremities or promote vasodilation and prevent vascular compression?) Increase in physical activity each day.(Increase arterial blood supply to the extremities or promote vasodilation and prevent vascular compression?) Do not use of bicotine products.(Increase arterial blood supply to the extremities or promote vasodilation and prevent vascular compression?) Wear warm clothing in the winter.(Increase arterial blood supply to the extremities or promote vasodilation and prevent vascular compression?) Avoid crossing the legs. (Increase arterial blood supply to the extremities or promote vasodilation and prevent vascular compression?)

Keep legs in a dependent position.(Increase arterial blood supply to the extremities) Increase in physical activity each day.(Increase arterial blood supply to the extremities) Do not use of bicotine products.(promote vasodilation and prevent vascular compression?) Wear warm clothing in the winter.(promote vasodilation and prevent vascular compression?) Avoid crossing the legs. (promote vasodilation and prevent vascular compression?)

A home health nurse is teaching a client with peripheral arterial disease ways to improve circulation to the lower extremities. The nurse encourages which of the following in teaching? Keeping the legs in a neutral or dependent position Application of ace wraps from the toe to below the knees Elevation of the legs above the heart Use of antiembolic stockings

Keeping the legs in a neutral or dependent position

The nurse is providing client education prior to a client's discharge home after treatment for heart failure. The nurse gives the client a home care checklist as part of the discharge teaching. What should be included on this checklist?

Know how to recognize and prevent orthostatic hypotension.

The clinical manifestations of cardiogenic shock reflect the pathophysiology of heart failure (HF). By applying this correlation, the nurse notes that the degree of shock is proportional to which of the following?

Left ventricular failure The signs and symptoms of cardiogenic shock reflect the circular nature of the pathophysiology of HF. The degree of shock is proportional to the extent of left ventricular dysfunction.

A nurse is preparing to teach a client who has a BMI of 32 about a heart-healthy diet. Which of the following dietary recommendations should the nurse include?

Limit sodium intake to less than 3000 mg/day.

The nurse is assigned to care for a client with heart failure. What medication does the nurse anticipate administering that will improve client symptoms as well as increase survival?

Lisinopril Several medications are routinely prescribed for heart failure (HF), including angiotensin-converting enzyme (ACE) inhibitors such as lisinopril, beta-blockers, and diuretics such as bumetanide. Many of these medications, particularly ACE inhibitors and beta-blockers, improve symptoms and extend survival. Others, such as diuretics, improve symptoms but may not affect survival. Calcium channel blockers such as diltiazem are no longer recommended for patients with HF because they are associated with worsening failure. Cholestyramine is used to lower cholesterol.

Which is the hallmark of heart failure?

Low ejaculation fraction (EF) Although a low EF is a hallmark of heart failure (HF), the severity of HF is frequently classified according to the client's symptoms. Pulmonary congestion, limitation of ADLs, and basilar crackles are all symptoms of HF.

A nurse is collecting data from a client who has an abdominal aortic aneurysm. Which of the following manifestations should the nurse expect?

Lower Back Discomfort

With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by: -Elevating the limb over the heart level. -Massaging the limb after application of cold compresses. -Placing the limb in a plane horizontal to the body. -Lowering the limb so that it is dependent.

Lowering the limb so that it is dependent. Explanation: Lowering the extremity to a dependent position improves perfusion to the distal tissues. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, ARTERIAL DISORDERS, p. 829.

A client diagnosed with heart failure presents with a temperature of 99.1° F, pulse 100 beats/minute, respirations 42 breaths/minute, BP 110/50 mm Hg; crackles in both lung bases; nausea; and pulse oximeter reading of 89%. Which finding indicates a need for immediate attention?

Lung congestion

Which term refers to enlarged, red, and tender lymph nodes? Elephantiasis Lymphadenitis Lymphangitis Lymphedema

Lymphadenitis

Which of the following terms refers to enlarged, red, and tender lymph nodes? a) Lymphadenitis b) Lymphangitis c) Lymphedema d) Elephantiasis

Lymphadenitis Acute lymphadenitis is demonstrated by enlarged, red and tender lymph nodes. Lymphangitis is an acute inflammation of the lymphatic channels. Lymphedema is demonstrated by swelling of tissues in the extremities because of an increased quantity of lymph that results from an obstruction of lymphatic vessels. Elephantiasis refers to a condition in which chronic swelling of the extremity recedes only slightly with elevation.

A nurse is completing an assessment on a patient and discovers an enlarged, red, and tender lymph node. The nurse will describe and document the lymph node using which of the following terms? a) Lymphangitis b) Lymphedema c) Lymphadenitis d) Elephantiasis

Lymphadenitis Acute lymphadenitis is demonstrated by enlarged, red, and tender lymph nodes. Lymphangitis is an acute inflammation of the lymphatic channels. Lymphedema is demonstrated by swelling of tissues in the extremities because of an increased quantity of lymph that results from an obstruction of lymphatic vessels. Elephantiasis refers to a condition in which chronic swelling of the extremity recedes only slightly with elevation.

A nurse is completing an assessment on a client and discovers an enlarged, red, and tender lymph node. The nurse will describe and document the lymph node using which term? -Lymphadenitis -Lymphangitis -Lymphedema -Elephantiasis

Lymphadenitis Explanation: Acute lymphadenitis is demonstrated by enlarged, red, and tender lymph nodes. Lymphangitis is acute inflammation of the lymphatic channels. Lymphedema is demonstrated by swelling of tissues in the extremities because of an increased quantity of lymph that results from an obstruction of lymphatic vessels. Elephantiasis refers to a condition in which chronic swelling of the extremity recedes only slightly with elevation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Lymphangitis and Lymphadenitis, p. 860.

Which term refers to enlarged, red, and tender lymph nodes? -Lymphedema -Lymphadenitis -Lymphangitis -Elephantiasis

Aortic dissection may be mistaken for which of the following disease processes? Stroke Myocardial infarction (MI) Pneumothorax Angina

The nurse is caring for a client with upper extremity arterial disease. Which assessments will the nurse include in the client's plan of care? Select all that apply. -Encourage activities using the affected extremity. -Compare radial pulses on both wrists every 2 hours. -Place the affected extremity in a dependent position. -Assess capillary refill on both arms every 2 hours. -Measure blood pressure on both arms.

Measure blood pressure on both arms. Assess capillary refill on both arms every 2 hours. Compare radial pulses on both wrists every 2 hours. Explanation: Arterial stenosis and occlusions occur less frequently in the upper extremities than in the legs, and cause less severe symptoms because the collateral circulation is significantly better in the arms. However symptoms of upper extremity arterial disease include arm fatigue and pain with exercise, the inability to hold or grasp objects, and possible difficulty driving. The assessment of this client includes measuring blood pressure on both upper extremities since there may be a difference of more than 15 to 20 mm Hg because of the arterial occlusion. Capillary refill should also be assessed every 2 hours along with comparing the radial pulses on both wrists every 2 hours. Activities using the affected upper extremity can cause cramping and pain. There is no evidence that the dependent position is helpful when caring for a client with upper extremity arterial disease. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Upper Extremity Arterial Disease, p. 837.

The nurse is caring for a client with heart failure who is receiving torsemide. What implementation will help the nurse evaluate the client's response of the medication?

Measure input and output

A client is diagnosed with peripheral arterial disease. Review of the client's chart shows an ankle-brachial index (ABI) on the right of 0.45. This indicates that the right foot has which of the following? Very mild arterial insufficiency Tissue loss to that foot Moderate to severe arterial insufficiency No arterial insufficiency

Moderate to severe arterial insufficiency

A client is diagnosed with peripheral arterial disease. Review of the client's chart shows an ankle-brachial index (ABI) on the right of 0.45. This indicates that the right foot has which of the following? a) No arterial insufficiency b) Very mild arterial insufficiency c) Moderate to severe arterial insufficiency d) Tissue loss to that foot

Moderate to severe arterial insufficiency Normal people without arterial insufficiency have an ABI of about 1.0. Those with an ABI of 0.95 to 0.5 have mild to moderate arterial insufficiency. Those with an ABI of less than 0.50 have ischemic rest pain. Those with tissue loss have severe ischemia and an ABI of 0.25 or less.

A client is diagnosed with peripheral arterial disease. Review of the client's chart shows an ankle-brachial index (ABI) on the right of 0.45. This indicates that the right foot has which of the following? -Very mild arterial insufficiency -Tissue loss to that foot -Moderate to severe arterial insufficiency -No arterial insufficiency

Moderate to severe arterial insufficiency Explanation: Normal people without arterial insufficiency have an ABI of about 1.0. Those with an ABI of 0.95 to 0.5 have mild to moderate arterial insufficiency. Those with an ABI of less than 0.50 have ischemic rest pain. Those with tissue loss have severe ischemia and an ABI of 0.25 or less. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Doppler Ultrasound Flow Studies, p. 824.

Which action will the nurse include in the plan of care for a client admitted with acute decompensated heart failure (ADHF) who is receiving milrinone?

Monitor blood pressure frequently

A nurse is administering a loop diuretic to a client who has 3+ pitting edema in the lower extremities. Which of the following actions should the nurse take?

Monitor the client for ototoxicity

The nurse is providing discharge education to a client diagnosed with heart failure. What should the nurse teach this client to do to assess fluid balance in the home setting?

Monitor weight daily.

A client develops cardiogenic pulmonary edema and is extremely apprehensive. What medication can the nurse administer with physician orders that will relieve anxiety and slow respiratory rate?

Morphine sulfate Morphine seems to help relieve respiratory symptoms by depressing higher cerebral centers, thus relieving anxiety and slowing respiratory rate. Morphine also promotes muscle relaxation and reduces the work of breathing. Furosemide is a loop diuretic and will decrease fluid accumulation but will not reduce anxiety. Nitroglycerin will promote smooth muscle relaxation in the vessel walls and will relieve pain but not reduce anxiety. Dopamine is an inotrope that will increase the force of ventricular contraction but will not alleviate anxiety.

Aortic dissection may be mistaken for which of the following disease processes? a) Myocardial infarction (MI) b) Angina c) Stroke d) Pneumothorax

Myocardial infarction (MI) Aortic dissection may be mistaken for an acute MI, which could confuse the clinical picture and initial treatment. Aortic dissection is not mistaken for stroke, pneumothorax, or angina.

Aortic dissection may be mistaken for which of the following disease processes? -Stroke -Angina -Pneumothorax -Myocardial infarction (MI)

Myocardial infarction (MI) Explanation: Aortic dissection may be mistaken for an acute MI, which could confuse the clinical picture and initial treatment. Aortic dissection is not mistaken for stroke, pneumothorax, or angina. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Aortic Dissection, p. 841.

A nurse is teaching clients newly diagnosed with coronary heart disease (CHD) about the disease process and risk factors for heart failure. Which problem can cause left-sided heart failure (HF)?

Myocardial ischemia Myocardial dysfunction and HF can be caused by a number of conditions, including coronary artery disease, hypertension, cardiomyopathy, valvular disorders, and renal dysfunction with volume overload. Atherosclerosis of the coronary arteries is a primary cause of HF, and coronary artery disease is found in the majority of clients with HF. Ischemia causes myocardial dysfunction because it deprives heart cells of oxygen and causes cellular damage. MI causes focal heart muscle necrosis, myocardial cell death, and a loss of contractility; the extent of the infarction correlates with the severity of HF. Left-sided heart failure is caused by myocardial ischemia. Ineffective right ventricular contraction, pulmonary embolus, and cystic fibrosis cause right-sided heart failure.

The nurse is caring for a client with severe compensated heart failure. What human brain natriuretic peptide (BNP) medication may be used in a critical care unit with hemodynamic monitoring?

Natrecor Nesiritide (Natrecor) is a preparation of human BNP that mimics the action of endogenous BNP, causing diuresis and vasodilation, reducing blood pressure, and improving cardiac output. Frequently this medication is titrated in a critical care unit for client safety. It is a preload and afterload reducer. Metoprolol is a beta-blocker. Captopril and enalapril are angiotensin-converting enzyme (ACE) inhibitors.

A client is prescribed digitalis medication. Which condition should the nurse closely monitor when caring for the client?

Nausea and vomit

A nurse is assessing a client who has left-sided heart failure with decreased cardiac output. Which of the following manifestations should the nurse expect? Flushing of the skin on exertion Nocturia at night Warm lower extremities Respiratory rate of 16/min

Nocturia at night Flushing of the skin on exertion The client who has left-sided heart failure with decreased cardiac output will appear pale in color on exertion due to poor tissue perfusion. Nocturia at night The client who has left-sided heart failure with decreased cardiac output can have oliguria during the day and nocturia at night due to poor tissue perfusion to the kidneys. Warm lower extremities The client who has left-sided heart failure with decreased cardiac output will have cool extremities due to poor tissue perfusion. Respiratory rate of 16/min The client who has left-sided heart failure with decreased cardiac output will have tachypnea due to intra-alveolar fluid causing engorgement of pulmonary vessels.

The nurse is discussing discharge teaching with the client who is three (3) days postoperative abdominal aortic aneurysm repair. Which discharge instructions should the nurse include when teaching the client?

Notify the HCP of any redness or irritation of the incision.

A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment? a) Swelling, warm skin temperature, and drainage b) Numbness, warm skin temperature, and redness c) Numbness, cool skin temperature, and pallor d) Redness, cool skin temperature, and swelling

Numbness, cool skin temperature, and pallor Signs and symptoms of impaired circulation include numbness and cool, pale skin. Signs of localized infection may include swelling, drainage, redness, and warm skin. Signs of adequate circulation include normal sensation and warm skin with normal return of skin color after blanching.

A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment? -Redness, cool skin temperature, and swelling -Swelling, warm skin temperature, and drainage -Numbness, warm skin temperature, and redness -Numbness, cool skin temperature, and pallor

Numbness, cool skin temperature, and pallor Explanation: Signs and symptoms of impaired circulation include numbness and cool, pale skin. Signs of localized infection may include swelling, drainage, redness, and warm skin. Signs of adequate circulation include normal sensation and warm skin with normal return of skin color after blanching. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Assessment of the Vascular System, p. 822.

Which risk factor is related to venous stasis for deep vein thrombosis (DVT) and pulmonary embolism (PE)? Surgery Obesity Trauma Pacing wires

Obesity

Which of the following are risk factors for venous disorders of the lower extremities? a) Trauma b) Pacing wires c) Obesity d) Surgery

Obesity Careful assessment is invaluable in detecting early signs of venous disorders of the lower extremities. Patients with a history of varicose veins, hypercoagulation, neoplastic disease, cardiovascular disease, or recent major surgery or injury are at high risk. Other patients at high risk include those who are obese or older adults and women taking oral contraceptives.

Which of the following are risk factors related to venous stasis for DVT and pulmonary embolism? a) Trauma b) Surgery c) Obesity d) Pacing wires

Obesity Obesity is a risk factor for DVT and PE related to venous stasis. Trauma, pacing wires, and surgery are related to endothelial damage as a risk factor for DCAT and PE.

A nurse is collecting data from a client who reports using fish oil as a dietary supplement. Which of the following substances in fish oil should the nurse recognize as a health benefit to the client?

Omega-3 fatty acids

A patient with impaired renal function is scheduled for a multidetector computer tomography (MDCT) scan. What preprocedure medication may the nurse administer to this patient? Epinephrine Dipyridamole (Persantine) Oral N-acetylcysteine Oral iodine

Oral N-acetylcysteine

A nurse reviews the client's medical record and reads in the progress notes that the client has decreased left ventricular function. What assessment will validate the diagnosis?

Orthopnea

What part of the ECG would you look for atrial depolarization?

P wave - atrial depolarization QRS- vetricular depolarization T- Ventricular reploarization

A client who is diagnosed with Raynaud syndrome reports cold and numbness in the fingers. Which finding should the nurse identify as an early sign of vasoconstriction? Pallor Cyanosis Gangrene Ulceration

Pallor

A client who is diagnosed with Raynaud syndrome reports cold and numbness in the fingers. Which finding should the nurse identify as an early sign of vasoconstriction? -Gangrene -Clubbing of the fingers -Cyanosis -Pallor

Pallor Explanation: Pallor is the initial symptom in Raynaud syndrome followed by cyanosis and aching pain. Gangrene and ulceration can occur with persistent attacks and interference of blood flow. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Raynaud's Phenomenon and Other Acrosyndromes, p. 844.

A nurse is caring for a client who has a foot ulcer. Which of the following findings should the nurse identify as consistent with peripheral venous disease?

Palpable dorsalis pedal pulse

A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities? Participate in a regular walking program. Massage the calf muscles if pain occurs. Keep the extremities elevated slightly. Use a heating pad to promote warmth.

Participate in a regular walking program.

Cardiopulmonary resuscitation has been initiated on a client who was found unresponsive. When performing chest compressions, the nurse should do which of the following actions?

Perform at least 100 chest compressions per minute.

A client is receiving captopril for heart failure. During the nurse's assessment, what sign indicates that the medication therapy is ineffective?

Peripheral edema Peripheral edema is a sign of fluid volume excess and worsening heart failure. A skin rash, dry cough, and postural hypotension are adverse reactions to captopril, but they don't indicate that therapy is ineffective.

A nurse is caring for a client following an arterial vascular bypass graft in the leg. Over the next 24 hours, what should the nurse plan to assess? a) Blood pressure every 2 hours b) Color of the leg every 4 hours c) Peripheral pulses every 15 minutes following surgery d) Ankle-arm indices every 12 hours

Peripheral pulses every 15 minutes following surgery The primary objective in the postoperative period is to maintain adequate circulation through the arterial repair. Pulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the patient's status remains stable. (less)

The client with cardiac failure is taught to report which symptom to the physician or clinic immediately?

Persistent cough Persistent cough may indicate an onset of left-sided heart failure. Loss of appetite, weight gain, interrupted sleep, unusual shortness of breath, and increased swelling should also be reported immediately.

A nurse is collecting data from a client who has manifestations of aplastic anemia. Which of the following findings should the nurse expect?

Petechiae and ecchymosis

The nurse completes an assessment of a client admitted with a diagnosis of right-sided heart failure. What will be a significant clinical finding related to right-sided heart failure?

Pitting edema The presence of pitting edema is a significant sign of right-sided heart failure because it indicates fluid retention of about 10 lbs. Sodium and water are retained because reduced cardiac output causes a compensatory neurohormonal response. Oliguria is a sign of kidney failure or dehydration. The S4 heart sound is from a thickened left ventricle, seen with aortic stenosis or hypertension. The decreased oxygen saturation levels are from hypoxemia.

A nurse is caring for a client who is postoperative following vein ligation and stripping for varicose veins. Which of the following actions should the nurse take?

Position the client supine with his legs elevated when in bed

A patient complains of a "stabbing pain and a burning sensation" in his left foot. The nurse notices that the foot is a lighter color than the rest of the skin. The artery that the nurse suspects is occluded would be the: -Popliteal. -Posterior tibial. -Internal iliac. -Common femoral.

Posterior tibial. Explanation: Clinical symptoms of PAD are manifested in organs or muscle groups supplied by specific arterial blood flow. The posterior tibial artery is a major artery that is a common site for occlusion. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Doppler Ultrasound Flow Studies, p. 824.

A nurse is caring for a client who has heart failure and is lethargic with muscle weakness. The client's telemetry reading displays dysrhythmias. Which of the following laboratory results should the nurse anticipate?

Potassium 2.8 mEq/L

The nurse is caring for an adult client whom the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should monitor what assessment information?

Potassium Level

A nurse is caring for a client who has hemophilia. The client reports pain and swelling in a joint following an injury. Which of the following actions should the nurse take?

Prepare for replacement of the missing clotting factor

While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first? a) Decrease the heparin infusion rate. b) Start an I.V. infusion of dextrose 5% in water (D5W). c) Prepare to administer protamine sulfate. d) Monitor the partial thromboplastin time (PTT).

Prepare to administer protamine sulfate. Frank hematuria indicates excessive anticoagulation and bleeding — and heparin overdose. The nurse should discontinue the heparin infusion immediately and prepare to administer protamine sulfate, the antidote for heparin. Decreasing the heparin infusion rate wouldn't prevent further bleeding. Although the nurse should continue to monitor PTT, this action should occur later. An I.V. infusion of D5W may be administered, but only after protamine has been given.

The nurse's comprehensive assessment of a client who has heart failure includes evaluation of the client's hepatojugular reflux. What action should the nurse perform during this assessment?

Press the right upper abdomen.

The nurse is caring for a client with heart failure. What are the management goals for the client with heart failure? Select all that apply

Promoting a healthy lifestyle. Increasing cardiac output by strengthening muscle contractions. Lowering the risk for hospitalization.

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description? Plasma protein fraction Thrombin Phytonadione (vitamin K) Protamine sulfate

Protamine sulfate

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description? Thrombin Plasma protein fraction Phytonadione (vitamin K) Protamine sulfate

Protamine sulfate

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description? a) Thrombin b) Plasma protein fraction c) Phytonadione (vitamin K) d) Protamine sulfate

Protamine sulfate Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn't given orally.) Thrombin is a hemostatic agent used to control local bleeding. Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it's used to treat clients who are in shock

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description? -Thrombin -Plasma protein fraction -Protamine sulfate -Phytonadione (vitamin K)

Protamine sulfate Explanation: Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn't given orally.) Thrombin is a hemostatic agent used to control local bleeding. Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it's used to treat clients who are in shock. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Peripheral Artery Disease, p. 837.

A nurse is evaluating a clients repeat laboratory results 4 hr after administering fresh frozen plasma (FFP). Which of the following laboratory values should the nurse review?

Prothrombin time

A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs? Platelet count Prothrombin time (PT) Partial thromboplastin time (PTT) Bleeding time

Prothrombin time (PT

A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs? a) Prothrombin time (PT) b) Platelet count c) Partial thromboplastin time (PTT) d) Bleeding time

Prothrombin time (PT) PT determines a client's response to oral anticoagulant therapy. This test measures the time required for a fibrin clot to form in a citrated plasma sample following addition of calcium ions and tissue thromboplastin and compares this time with the fibrin-clotting time in a control sample. The physician should adjust anticoagulant dosages as needed, to maintain PT at 1.5 to 2.5 times the control value. Bleeding time indicates how long it takes for a small puncture wound to stop bleeding. The platelet count reflects the number of circulating platelets in venous or arterial blood. PTT determines the effectiveness of heparin therapy and helps physicians evaluate bleeding tendencies. Physicians diagnose appoximately 99% of bleeding disorders on the basis of PT and PTT values.

The nurse is caring for a client with abdominal aortic aneurysm (AAA). Which assessment finding is most likely to indicate a dissection of the aneurysm? Rectal bleeding Hypertensive crisis Severe pain Hematemesis

Severe pain

A physician orders blood coagulation tests to evaluate a client's blood-clotting ability. The nurse knows that such tests are important in assessing clients at risk for thrombi, such as those with a history of atrial fibrillation, infective endocarditis, prosthetic heart valves, or myocardial infarction. Which test determines a client's response to oral anticoagulant drugs? -Bleeding time -Prothrombin time (PT) -Partial thromboplastin time (PTT) -Platelet count

Prothrombin time (PT) Explanation: PT determines a client's response to oral anticoagulant therapy. This test measures the time required for a fibrin clot to form in a citrated plasma sample following addition of calcium ions and tissue thromboplastin and compares this time with the fibrin-clotting time in a control sample. The physician should adjust anticoagulant dosages as needed, to maintain PT at 1.5 to 2.5 times the control value. Bleeding time indicates how long it takes for a small puncture wound to stop bleeding. The platelet count reflects the number of circulating platelets in venous or arterial blood. PTT determines the effectiveness of heparin therapy and helps physicians evaluate bleeding tendencies. Physicians diagnose approximately 99% of bleeding disorders on the basis of PT and PTT values. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Deep Vein Thrombosis, p. 846.

A client with a history of an anterior wall myocardial infarction is being transferred from the coronary care unit (CCU) to the cardiac step-down unit (CSU). While giving a report to the CSU nurse, the CCU nurse says, "His pulmonary artery wedge pressures have been in the high normal range." What additional assessment information would be important for the CSU nurse to obtain?

Pulmonary crackles

A patient is admitted to the intensive care unit (ICU) with left-sided heart failure. What clinical manifestations does the nurse anticipate finding when performing an assessment? (Select all that apply.)

Pulmonary crackles Dyspnea Cough

The nurse notes that a client has developed dyspnea; a productive, mucoid cough; peripheral cyanosis; and noisy, moist-sounding, rapid breathing. These signs and symptoms suggest which health problem?

Pulmonary edema

What are complications of Heart failure?

Pulmonary edema Cardiogenic shock Cardiac tamponade

A client who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly reports chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the client for other signs and symptoms of

Pulmonary embolism Pulmonary embolism is a potentially life-threatening disorder typically caused by blood clots in the lungs. This disorder poses a particular threat to people with cardiovascular disease. Blood clots that form in the deep veins of the legs and embolize to the lungs can cause a pulmonary infarction, whereby emboli mechanically obstruct the pulmonary vessels, cutting off the blood supply to sections of the lung. Clinical indicators of pulmonary embolism can vary but typically include dyspnea, pleuritic chest pain, and tachypnea.

A cardiovascular client with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE. Which action is the nurse's best action?

Rapidly assess the client's cardiopulmonary status.

A client with systemic lupus erythematosus (SLE) complains that his hands become pale, blue, and painful when exposed to the cold. What disease should the nurse cite as an explanation for these signs and symptoms? Buerger's disease Peripheral vascular disease Arterial occlusive diseases Raynaud's disease

Raynaud's disease Explanation: Raynaud's disease results from reduced blood flow to the extremities when exposed to cold or stress. It's commonly associated with connective tissue disorders such as SLE. Signs and symptoms include pallor, coldness, numbness, throbbing pain, and cyanosis. Peripheral vascular disease results from a reduced blood supply to the tissues. It occurs in the arterial or venous system. Build-up of plaque in the vessels or changes in the vessels results in reduced blood flow, causing pain, edema, and hair loss in the affected extremity. Arterial occlusive disease is the obstruction or narrowing of the lumen of the aorta and its major branches that interrupts blood flow to the legs and feet, causing pain and coolness. Buerger's disease is an inflammatory, nonatheromatous occlusive disease that causes segmental lesions and subsequent thrombus formation in arteries, resulting in decreased blood flow to the feet and legs.

A client with systemic lupus erythematosus (SLE) complains that his hands become pale, blue, and painful when exposed to the cold. What disease should the nurse cite as an explanation for these signs and symptoms? a) Buerger's disease b) Arterial occlusive diseases c) Peripheral vascular disease d) Raynaud's disease

Raynaud's disease Raynaud's disease results from reduced blood flow to the extremities when exposed to cold or stress. It's commonly associated with connective tissue disorders such as SLE. Signs and symptoms include pallor, coldness, numbness, throbbing pain, and cyanosis. Peripheral vascular disease results from a reduced blood supply to the tissues. It occurs in the arterial or venous system. Build-up of plaque in the vessels or changes in the vessels results in reduced blood flow, causing pain, edema, and hair loss in the affected extremity. Arterial occlusive disease is the obstruction or narrowing of the lumen of the aorta and its major branches that interrupts blood flow to the legs and feet, causing pain and coolness. Buerger's disease is an inflammatory, nonatheromatous occlusive disease that causes segmental lesions and subsequent thrombus formation in arteries, resulting in decreased blood flow to the feet and legs.

A client with systemic lupus erythematosus (SLE) complains that his hands become pale, blue, and painful when exposed to the cold. What disease should the nurse cite as an explanation for these signs and symptoms? -Raynaud's disease -Arterial occlusive diseases -Buerger's disease -Peripheral vascular disease

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important? History of increased aspirin use Recent pelvic surgery An active daily walking program A history of diabetes mellitus

Recent pelvic surgery

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important? a) A history of diabetes mellitus b) Recent pelvic surgery c) An active daily walking program d) History of increased aspirin use

Recent pelvic surgery The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes mellitus is a contributing factor associated with peripheral vascular disease

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important? -History of increased aspirin use -Recent pelvic surgery -An active daily walking program -A history of diabetes mellitus

Recent pelvic surgery Explanation: The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes mellitus is a contributing factor associated with peripheral vascular disease. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Deep Vein Thrombosis, p. 846.

The nurse observes a client with an onset of heart failure having rapid, shallow breathing at a rate of 32 breaths/minute. What blood gas analysis does the nurse anticipate finding initially?

Respiratory alkalosis At first, arterial blood gas analysis may reveal respiratory alkalosis as a result of rapid, shallow breathing. Later, there is a shift to metabolic acidosis as gas exchange becomes more impaired. Respiratory acidosis and metabolic alkalosis are incorrect distractors.

The nurse recognizes which symptom as a classic sign of cardiogenic shock?

Restlessness and confusion Cardiogenic shock occurs when decreased cardiac output leads to inadequate tissue perfusion and initiation of the shock syndrome. Inadequate tissue perfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation).

Which of the following is the most effective intervention for preventing progression of vascular disease? Risk factor modification Avoid trauma Wear sturdy shoes Use neutral soaps

Risk factor modification

Which of the following is the most effective intervention for preventing progression of vascular disease? Risk factor modification Wear sturdy shoes Avoid trauma Use neutral soaps

Which of the following is the most effective intervention for preventing progression of vascular disease? -Risk factor modification -Use neutral soaps -Avoid trauma -Wear sturdy shoes

Risk factor modification Explanation: Risk factor modification is the most effective intervention for preventing progression of vascular disease. Measures to prevent tissue loss and amputation are a high priority. Patients are taught to avoid trauma; wear sturdy, well-fitting shoes or slippers; and use pH neutral soaps and body lotions. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Arteriosclerosis and Atherosclerosis, p. 833.

A nurse is admitting a new client with a deep vein thrombosis in her left leg. During the admission process, which information provided by the client would be a contraindication to anticoagulant therapy? -Three vaginal births, the most recent 18 months ago -Diet that includes many green, leafy vegetables every day -A cerebral vascular bleed 10 years ago -Scheduled eye surgery in 1 week

Scheduled eye surgery in 1 week Explanation: Contraindications to anticoagulant therapy include recent or impending eye surgery, recent cerebral vascular bleeds, and recent childbirth. A diet including green leafy vegetables is not a contraindication. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Deep Vein Thrombosis, p. 847.

A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions? a) Increasing blood pressure and monitoring fluid intake and output b) Increasing blood pressure and reducing mobility c) Stabilizing heart rate and blood pressure and easing anxiety d) Decreasing blood pressure and increasing mobility

Stabilizing heart rate and blood pressure and easing anxiety For a client with an aneurysm, nursing interventions focus on preventing aneurysm rupture by stabilizing heart rate and blood pressure. Easing anxiety also is important because anxiety and increased stimulation may raise the heart rate and boost blood pressure, precipitating aneurysm rupture. The client with an abdominal aortic aneurysm is typically hypertensive, so the nurse should take measures to lower blood pressure, such as administering antihypertensive agents, as ordered, to prevent aneurysm rupture. To sustain major organ perfusion, the client should maintain a mean arterial pressure of at least 60 mm Hg. Although the nurse must assess each client's mobility individually, most clients need bed rest when initially attempting to gain stability

A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions? a) Decreasing blood pressure and increasing mobility b) Stabilizing heart rate and blood pressure and easing anxiety c) Increasing blood pressure and reducing mobility d) Increasing blood pressure and monitoring fluid intake and output

A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions? -Stabilizing heart rate and blood pressure and easing anxiety -Increasing blood pressure and monitoring fluid intake and output -Increasing blood pressure and reducing mobility -Decreasing blood pressure and increasing mobility

Stabilizing heart rate and blood pressure and easing anxiety Explanation: For a client with an aneurysm, nursing interventions focus on preventing aneurysm rupture by stabilizing heart rate and blood pressure. Easing anxiety also is important because anxiety and increased stimulation may raise the heart rate and boost blood pressure, precipitating aneurysm rupture. The client with an abdominal aortic aneurysm is typically hypertensive, so the nurse should take measures to lower blood pressure, such as administering antihypertensive agents, as ordered, to prevent aneurysm rupture. To sustain major organ perfusion, the client should maintain a mean arterial pressure of at least 60 mm Hg. Although the nurse must assess each client's mobility individually, most clients need bed rest when initially attempting to gain stability. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Abdominal Aortic Aneurysm, p. 840.

Which of the following are alterations noted in Virchow's triad? Select all that apply. -Edema -Vessel wall injury -Altered coagulation -Tenderness -Stasis of blood

Stasis of blood Vessel wall injury Altered coagulation Three factors, known as Virchow's triad, are believed to play a significant role in the development of venous thrombosis. They are stasis of blood, vessel wall injury, and altered coagulation. Edema and tenderness are clinical manifestations of venous thrombosis, but are not part of the triad. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Venous Thromboembolism, p. 845.

Which of the following are alterations noted in Virchow's triad? Select all that apply. Altered coagulation Vessel wall injury Tenderness Stasis of blood Edema

Stasis of bloodVessel wall injuryAltered coagulation

A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client? Wear antiembolic stockings daily to assist with blood return to the heart. Keep your feet elevated above your heart. Stop smoking. Do not cross your legs for more than 30 minutes at a time.

Stop smoking.

A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client? a) Stop smoking. b) Wear antiembolytic stockings daily to assist with blood return to the heart. c) Do not cross your legs for more than 30 minutes at a time. d) Keep your feet elevated above your heart.

Stop smoking. Nicotine from tobacco products causes vasospasm and can thereby dramatically reduce circulation to the extremities. When the client elevates the feet above the heart level, the heart must work against gravity to supply blood to the feet. Antiembolytic stocking are helpful for venous return to the heart, but constriction is not helpful for lack of arterial blood flow. Crossing the legs for more than a few minutes at a time compresses arteries and decreases blood supply to the legs and feet.

A nurse is monitoring a client who is receiving a unit of packed red blood cells (RBCs) following surgery. The client reports itching and has hives 30 min after the infusion begins. Which of the following actions should the nurse take first?

Stop the infusion of blood

A nurse in the critical care unit is caring for a client with heart failure who has developed an intracardiac thrombus. The nurse should assess for signs and symptoms of which sequela?

Stroke

Which is a manifestation of right-sided heart failure?

Systemic venous congestion Right-sided heart failure causes systemic venous congestion and a reduction in forward flow. Left-sided heart failure causes an accumulation of blood in the lungs and a reduction in forward flow or cardiac output that results in inadequate arterial blood flow to the tissues. Some clients with left-sided heart failure get episodes of dyspnea at night, known as paroxysmal nocturnal dyspnea.

In a patient with suspected superficial VTE in the calf, the abnormalities in the lower extremity are potentially enhanced by having the patient stand for 2 minutes.

TRUE

One of the potential serious adverse effects of unfractionated heparin is thrombocytopenia.

TRUE

Prescribing a direct thrombin inhibitor is an acceptable therapeutic option to reduce the risk of recurrent DVT.

TRUE

True or False? During the first 6 weeks of the postpartum period, the childbearing woman is at increased risk of VTE.

TRUE

True or False? In treatment of venous stasis ulcer that is not responsive to standard therapy, other options include hyperbaric oxygen therapy?

TRUE

Right sided Heart failure results in peripheral edema? TRUE OR FALSE

TRUE**Right side Heart failure results in inadequate right ventricle output and systemic congestion (peripheral edema)

As few as 3 days of malnutrition in the form of inadequate protein-calorie intake can impair normal wound healing mechanisms

TURE

The nurse is educating an 80-year-old client diagnosed with heart failure about the medication regimen. Which instruction would the nurse give this client about the use of oral diuretics?

Take the diuretic in the morning to avoid interfering with sleep.

On a routine visit to the physician, a client with chronic arterial occlusive disease reports that he's stopped smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, which additional measure should the nurse recommend? a) Engaging in anaerobic exercise b) Taking daily walks c) Abstaining from foods that increase levels of high-density lipoproteins (HDLs) d) Reducing daily fat intake to less than 45% of total calories

Taking daily walks Taking daily walks relieves symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may make these symptoms worse. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat, not abstain from, foods that raise HDL levels.

On a routine visit to the physician, a client with chronic arterial occlusive disease reports that he's stopped smoking after 34 years. To relieve symptoms of intermittent claudication, a condition associated with chronic arterial occlusive disease, which additional measure should the nurse recommend? -Reducing daily fat intake to less than 45% of total calories -Taking daily walks -Abstaining from foods that increase levels of high-density lipoproteins (HDLs) -Engaging in anaerobic exercise

Taking daily walks Explanation: Taking daily walks relieves symptoms of intermittent claudication, although the exact mechanism is unclear. Anaerobic exercise may make these symptoms worse. Clients with chronic arterial occlusive disease must reduce daily fat intake to 30% or less of total calories. The client should limit dietary cholesterol because hyperlipidemia is associated with atherosclerosis, a known cause of arterial occlusive disease. However, HDLs have the lowest cholesterol concentration, so this client should eat, not abstain from, foods that raise HDL levels. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Assessment of the Vascular System, p. 822.

Which health-care provider's order should the nurse question in a client diagnosed with an expanding abdominal aortic aneurysm who is scheduled for surgery in the morning?

Tap water enema until clear fecal return.

What should the nurse do to manage persistent swelling in a client with severe lymphangitis and lymphadenitis? Avoid elevating the area. Inform the physician if the client's temperature remains low. Offer cold applications to promote comfort and to enhance circulation. Teach the client how to apply a graduated compression stocking.

Teach the client how to apply a graduated compression stocking.

What should the nurse do to manage the persistent swelling in a client with severe lymphangitis and lymphadenitis? Teach the client how to apply an elastic sleeve Avoid elevating the area Offer cold applications to promote comfort and to enhance circulation Inform the physician if the client's temperature remains low

Teach the client how to apply an elastic sleeve

What should the nurse do to manage the persistent swelling in a client with severe lymphangitis and lymphadenitis? -Teach the client how to apply an elastic sleeve -Offer cold applications to promote comfort and to enhance circulation -Avoid elevating the area -Inform the physician if the client's temperature remains low

Teach the client how to apply an elastic sleeve Explanation: In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the client how to apply an elastic sleeve or stocking. The nurse informs the physician if the client's temperature remains elevated. The nurse recommends elevating the area to reduce the swelling and provides warmth to promote comfort and to enhance circulation. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Chronic Venous Insufficiency/ Postthrombotic Syndrome, pp. 853-854.

What should the nurse do to manage the persistent swelling in a patient with severe lymphangitis and lymphadenitis? a) Inform the physician if the temperature remains low. b) Teach the patient how to apply a graduated compression stocking. c) Avoid elevating the area. d) Offer cold applications to promote comfort and to enhance circulation.

Teach the patient how to apply a graduated compression stocking. In severe cases of lymphangitis and lymphadenitis with persistent swelling, the nurse teaches the patient how to apply a graduated compression stocking. The nurse informs the physician if the temperature remains elevated. The nurse recommends elevating the area to reduce the swelling and provides warmth to promote comfort and to enhance circulation.

What should the nurse do to manage the persistent swelling in a patient with severe lymphangitis and lymphadenitis? a) Teach the patient how to apply a graduated compression stocking. b) Offer cold applications to promote comfort and to enhance circulation. c) Avoid elevating the area. d) Inform the physician if the temperature remains low.

The client is diagnosed with a small abdominal aortic aneurysm. Which interventions should be included in the discharge teaching?

Tell the client to exercise three (3) times a week for 30 minutes Encourage the client to eat a low-fat, low-cholesterol diet Discuss the importance of losing weight with the client.

A patient with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which of the following is the most likely cause? a) The patient is experiencing inflammation of the aneurysm. b) The patient is experiencing normal sensations associated with this condition. c) The aneurysm has become obstructed. d) The aneurysm may be preparing to rupture.

The aneurysm may be preparing to rupture. Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Abdominal pain is often localized in the middle or lower abdomen to the left of the midline. Low back pain may be present because of pressure of the aneurysm on the lumbar nerves. Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit. Rupture into the peritoneal cavity is rapidly fatal. A retroperitoneal rupture of an aneurysm may result in hematomas in the scrotum, perineum, flank, or penis.

A client with a diagnosed abdominal aortic aneurysm (AAA) develops severe lower back pain. Which is the most likely cause? -The aneurysm may be preparing to rupture. -The client is experiencing inflammation of the aneurysm. -The aneurysm has become obstructed. -The client is experiencing normal sensations associated with this condition.

The aneurysm may be preparing to rupture. Explanation: Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Abdominal pain is often localized to the middle or lower abdomen to the left of the midline. Low-back pain may be present because of pressure of the aneurysm on the lumbar nerves. Indications of a rupturing AAA include constant, intense back pain; falling blood pressure; and decreasing hematocrit. Rupture into the peritoneal cavity is quickly fatal. A retroperitoneal rupture of an aneurysm may result in hematomas in the scrotum, perineum, flank, or penis. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Abdominal Aortic Aneurysm, p. 840.

The nurse overseeing care in the ICU reviews the shift report on four clients. The nurse recognizes which client to be at greatest risk for the development of cardiogenic shock?

The client admitted following an MI

A nurse and physician are preparing to visit a hospitalized client with peripheral arterial disease. As you approach the client's room, the physician asks if the client has reported any intermittent claudication. The client has reported this symptom. The nurse explains to the physician which of the following details? The client experiences shortness of breath after walking about 50 feet. The client's legs awaken him during the night with itching. The client's fingers tingle when left in one position for too long. The client can walk about 50 feet before getting pain in the right lower leg.

The client can walk about 50 feet before getting pain in the right lower leg.

A nurse and physician are preparing to visit a hospitalized client with peripheral arterial disease. As you approach the client's room, the physician asks if the client has reported any intermittent claudication. The client has reported this symptom. The nurse explains to the physician which of the following details? -The client can walk about 50 feet before getting pain in the right lower leg. -The client's fingers tingle when left in one position for too long. -The client's legs awaken him during the night with itching. -The client experiences shortness of breath after walking about 50 feet.

The client can walk about 50 feet before getting pain in the right lower leg. Explanation: Intermittent claudication is caused by the inability of the arterial system to provide adequate blood flow to the tissues when increased demands are made for oxygen and nutrients during exercise. Pain is then experienced. When the client rests and decreases demands, the pain subsides. The client can then walk the same distance and repeat the process. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Assessment of the Vascular System, p. 822.

A pregnant client who developed deep vein thrombosis (DVT) in her right leg is receiving heparin I.V. on the medical floor. Physical therapy is ordered to maintain her mobility and prevent additional DVT. A nursing assistant working on the medical unit helps the client with bathing, range-of-motion exercises, and personal care. Which collaborative multidisciplinary considerations should the care plan address? -The client is at risk for developing another DVT; therefore, the care plan should include reporting redness, tenderness, or edema in the other lower extremity. -The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising. -The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include sequential compression device application and strict bed rest. -The client is pregnant and receiving I.V. heparin, placing her at risk for premature labor; therefore, the care plan should include reporting signs of premature labor.

The client is at risk for heparin-induced thrombocytopenia; therefore, the care plan should include reporting evidence of bleeding or easy bruising. Explanation: Feedback about possible bleeding and bruising from physical therapy and other caregivers should be incorporated into the care plan to ensure safety and optimal outcomes. Using a sequential compression device, mandating strict bed rest, and reporting signs of DVT don't incorporate collaborative care. Reporting signs of premature labor doesn't address the consequences of thrombocytopenia, which may occur with I.V. heparin therapy. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Deep Vein Thrombosis, p. 847.

Assessment of a client on a medical surgical unit finds a regular heart rate of 120 beats per minute, audible third and fourth heart sounds, blood pressure of 84/64 mm Hg, bibasilar crackles on lung auscultation, and a urine output of 5 mL over the past hour. What is the reason the nurse anticipates transferring the client to the intensive care unit?

The client is going into cardiogenic shock.

A nurse is assisting in collecting data from a client who has a history of unstable angina. Which of the following findings should the nurse expect?

The client reports chest pain when at rest

The nurse is assessing an older adult client with numerous health problems. Which assessment finding indicates an increase in the client's risk for heart failure?

The client's age is greater than 65.

The client is one (1) day postoperative abdominal aortic aneurysm repair. Which information from the unlicensed assistive personnel (UAP) would require immediate intervention from the nurse?

The client's urinary output is 90 mL in six (6) hours.

The client asks the nurse why a stress test is needed. What statement best explains the rationale for the health care provider to order a cardiac stress test?

The health care provider wants to identify if the heart failure is from coronary artery disease

A nurse is teaching a client about heart failure. What will the nurse explain is causing the heart to fail?

The heart cannot pump sufficient blood to meet the body's metabolic needs

A patient is receiving enoxaparin (Lovenox) and warfarin (Coumadin) therapy for a venous thromboembolism (VTE). Which lab value indicates that anticoagulation is adequate and enoxaparin (Lovenox) can be discontinued? a) The patient's activated partial thromboplastin time (aPPT) is half of the control value. b) The patient's K+ level is 3.5. c) The patient's prothrombin time (PT) is 0.5 times normal. d) The patient's international normalized ratio (INR) is 2.5.

The patient's international normalized ratio (INR) is 2.5. Oral anticoagulants, such as warfarin, are monitored by the PT or the INR. Because the full anticoagulant effect of warfarin is delayed for 3 to 5 days, it is usually administered concurrently with heparin until desired anticoagulation has been achieved (ie, when the PT is 1.5 to 2 times normal or the INR is 2.0 to 3.0)

A client with venous insufficiency develops varicose veins in both legs. Which statement about varicose veins is accurate? a) The severity of discomfort isn't related to the size of varicosities. b) Sclerotherapy is used to cure varicose veins. c) Primary varicose veins are caused by deep vein thrombosis (DVT) and inflammation. d) Varicose veins are more common in men than in women.

The severity of discomfort isn't related to the size of varicosities. Clients with varicose veins commonly complain of aching, heaviness, itching, moderate swelling, and unsightly appearance of the legs. However, the severity of discomfort is hard to assess and seems unrelated to the size of varicosities. Varicose veins are more common in women than in men. Primary varicose veins typically result from a congenital or familial predisposition that makes the vein wall less elastic; secondary varicosities occur when trauma, obstruction, DVT, or inflammation damages valves. Sclerotherapy, in which a sclerosing agent is injected into a vein, is used to treat varicose veins; it doesn't cure them.

The most important factor regulating the caliber of blood vessels, which determines resistance to flow, is: Hormonal secretion. The influence of circulating chemicals. Independent arterial wall activity. The sympathetic nervous system.

The sympathetic nervous system.

Which of the following is the most common site for a dissecting aneurysm? Sacral area Cervical area Lumbar area Thoracic area

Thoracic area

Which of the following is the most common site for a dissecting aneurysm? a) Sacral area b) Thoracic area c) Cervical area d) Lumbar area

Thoracic area The thoracic area is the most common site for a dissecting aneurysm. About one-third of patients with thoracic aneurysms die of rupture of the aneurysm.

Which of the following is the most common site for a dissecting aneurysm? -Lumbar area -Thoracic area -Sacral area -Cervical area

Thoracic area Explanation: The thoracic area is the most common site for a dissecting aneurysm. About one-third of patients with thoracic aneurysms die of rupture of the aneurysm. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Thoracic Aortic Aneurysm, p. 839.

Which is a classic sign of cardiogenic shock?

Tissue hypoperfusion Tissue hypoperfusion is manifested as cerebral hypoxia (restlessness, confusion, agitation). Low blood pressure is a classic sign of cardiogenic shock. Hypoactive bowel sounds are classic signs of cardiogenic shock. Decreased urinary output is a classic sign of cardiogenic shock.

A client with a history of heart failure is returning from the operating room after inguinal hernia repair and the nurse assesses a low pulse oximetry reading. What is the most important nursing intervention?

Titrate oxygen therapy. The nurse needs to titrate oxygen therapy to increase the client's oxygen levels. Assessing for jugular vein distention and examining the surgical incision area will not meet the oxygen demands. Administering pain medication will not increase oxygenation levels.

The nurse is caring for a patient with venous insufficiency. For what should the nurse assess the patient's lower extremities? -Rubor -Dermatitis -Cellulitis -Ulceration

Ulceration Explanation: Venous ulceration is the most serious complication of chronic venous insufficiency and can be associated with other conditions affecting the circulation of the lower extremities. Cellulitis or dermatitis may complicate the care of chronic venous insufficiency and venous ulcerations. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Chronic Venous Insufficiency/ Postthrombotic Syndrome, p. 853.

What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue? Evident scarring Ulcers and infection in the edematous area Loose and wrinkled skin Cyanosis

Ulcers and infection in the edematous area

What are the symptoms a nurse should assess for in a patient with lymphedema as a result of impaired nutrition to the tissue? a) Loose and wrinkled skin b) Ulcers and infection in the edematous area c) Cyanosis d) Evident scaring

Ulcers and infection in the edematous area In a patient with lymphedema, the tissue nutrition is impaired from the stagnation of lymphatic fluid, leading to ulcers and infection in the edematous area. Later, the skin also appears thickened, rough, and discolored. Scaring does not occur in patients with lymphedema, and cyanosis is a bluish discoloration of the skin and mucous membranes

Ulcers and infection in the edematous area In a patient with lymphedema, the tissue nutrition is impaired from the stagnation of lymphatic fluid, leading to ulcers and infection in the edematous area. Later, the skin also appears thickened, rough, and discolored. Scarring does not occur in patients with lymphedema, and cyanosis is a bluish discoloration of the skin and mucous membranes.

What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue? -Cyanosis -Evident scarring -Ulcers and infection in the edematous area -Loose and wrinkled skin

Ulcers and infection in the edematous area Explanation: In a client with lymphedema, the tissue nutrition is impaired because of the stagnation of lymphatic fluid, leading to ulcers and infection in the edematous area. Later, the skin also appears thickened, rough, and discolored. Scarring does not occur in clients with lymphedema. Cyanosis is a bluish discoloration of the skin and mucous membranes. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, The Patient with Leg Ulcers, p. 857.

Which medical treatment would be prescribed for the client with an AAA less than 3 cm?

Ultrasound every six (6) months

The student nurse is caring for a client with heart failure. Diuretics have been ordered. What method might be used with a debilitated client to help the nurse evaluate the client's response to diuretics?

Using a urinary catheter

The physician writes orders for a patient to receive an angiotensin II receptor blocker for treatment of heart failure. What medication does the nurse administer?

Valsartan (Diovan) Valsartan (Diovan) is the only angiotensin receptor blocker listed. Digitalis/digoxin (Lanoxin) is a cardiac glycoside. Metolazone (Zaroxolyn) is a thiazide diuretic. Carvedilol (Coreg) is a beta-adrenergic blocking agent (beta-blocker).

The nurse teaches the patient with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes which of the following? a) Slowed heart rate b) Vasospasm c) Diuresis d) Depression of the cough reflex

Vasospasm Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities. Tobacco smoke also impairs transport and cellular use of oxygen and increases blood viscosity. Patients with arterial insufficiency who smoke or chew tobacco must be fully informed of the effects of nicotine on circulation and be encouraged to stop.

The nurse is caring for a client who is scheduled to have a vein ligation in the morning. How would you describe a vein ligation to the client? a) Removal of the great saphenous vein. b) Removal of the small saphenous vein. c) Veins are tied off and removed. d) Veins are tied off and left in the leg.

Veins are tied off and left in the leg. A vein ligation is a procedure in which the affected veins are ligated (tied off) above and below the area of incompetent valves, but the dysfunctional vein remains. A vein stripping is the removal of the veins after being tied off.

The nurse is caring for a client who is scheduled to have a vein ligation in the morning. How would you describe a vein ligation to the client? -The great saphenous vein is removed. -The small saphenous vein is removed. -Veins are tied off and removed. -Veins are tied off and left in the leg.

Veins are tied off and left in the leg. Explanation: A vein ligation is a procedure in which the affected veins are ligated (tied off) above and below the area of incompetent valves, but the dysfunctional vein remains. A vein stripping is the removal of the veins after being tied off. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Varicose Veins, p. 859.

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gaiter area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect? Neither venous nor arterial insufficiency Trauma Venous insufficiency Arterial insufficiency

Venous insufficiency

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gater area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect? a) Venous insufficiency b) Neither venous nor arterial insufficiency c) Trauma d) Arterial insufficiency

Venous insufficiency Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gater area, and a reddish blue color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the anterior tibial area. Characteristics of arterial insufficiency ulcers include location at the tips of the toes, great pain, and circular shape with a pale to black ulcer base.

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gaiter area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect? -Trauma -Venous insufficiency -Neither venous nor arterial insufficiency -Arterial insufficiency

Venous insufficiency Explanation: Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gaiter area, and a reddish blue color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the anterior tibial area. Characteristics of arterial insufficiency ulcers include location at the tips of the toes, great pain, and circular shape with a pale to black ulcer base. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Chronic Venous Insufficiency/ Postthrombotic Syndrome, p. 853.

A client is awaiting the availability of a heart for transplant. What option may be available to the client as a bridge to transplant?

Ventricular assist device (VAD)

A nurse is assisting in monitoring a client who had a myocardial infarction. For which of the following complications should the nurse monitor in the first 24 hr?

Ventricular dysrhythmias

A nurse is assisting in developing the plan of care for an older adult client who is to receive a unit of packed red blood cells (RBCs). Which of the following actions should the nurse recommend?

Verify the information on the packed RBCs with another nurse.

The nurse is assisting a patient with peripheral arterial disease to ambulate in the hallway. What should the nurse include in the education of the patient during ambulation? "If you feel pain during the walk, keep walking until the end of the hallway is reached." "As soon as you feel pain, we will go back and elevate your legs." "If you feel any discomfort, stop and we will use a wheelchair to take you back to your room." "Walk to the point of pain, rest until the pain subsides, then resume ambulation."

Walk to the point of pain, rest until the pain subsides, then resume ambulation."

A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?

Weighing the client daily at the same time each day

A client with heart failure must be monitored closely after starting diuretic therapy. What is the best indicator for the nurse to monitor?

Weight

A nurse is caring for a client who has late-stage heart failure and is experiencing fluid volume overload. Which of the following finding should the nurse expect?

Weight gain of 1 kg (2.2 lb) in 1 day

The nurse is caring for a client who is known to have a high risk for venous thromboembolism. What preventive actions should the nurse recommend? Select all that apply. -Regular exercise -Smoking cessation -Weight loss -Calcium and vitamin D supplementation -High-protein diet

Weight loss Regular exercise Smoking cessation Explanation: Clients at risk for VTE should be advised to make lifestyle changes, as appropriate, which may include weight loss, smoking cessation, and regular exercise. Increased protein intake and supplementation with vitamin D and calcium do not address the main risk factors for VTE. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Venous Thromboembolism, p. 845.

Which nursing intervention should the nurse perform when a client with valvular disorder of the heart has a heart rate less than 60 beats/min before administering beta-blockers?

Withhold the drug and inform the primary health care provider.

A nurse is assisting in the preparation of a unit of packed red blood cells (RBCs) for a client who has anemia. Which of the following actions should the nurse take first?

Witness informed consent.

client with a history of aching leg pain seeks medical attention for the development of a leg wound. Which assessment findings indicate to the nurse that the client is experiencing a venous ulcer? Select all that apply. Wound has an irregular border Thick, tough skin around the ankles Darkened skin around the lower extremities Wound is superficial Wound base is pale in color

Wound is superficialWound has an irregular borderThick, tough skin around the anklesDarkened skin around the lower extremities

The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is a) a lymphoscintigraphy. b) a contrast phlebography. c) an air plethysmography. d) a lymphangiography.

a contrast phlebography. When a thrombus exists, an x-ray image will disclose an unfilled segment of a vein. Air plethysmography quantifies venous reflux and calf muscle pump ejection. In lymphangiography, contrast media are injected into the lymph system. In a lymphoscintigraphy, a radioactive-labeled colloid is injected into the lymph system.

While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). How should the nurse document this sound?

a third heart sound (S3).

The nurse teaches the patient with peripheral vascular disease (PVD) to refrain from smoking because nicotine causes a) depression of the cough reflex. b) diuresis. c) a vasospasm. d) a slowed heart rate.

a vasospasm. Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities. Nicotine has stimulant effects. Nicotine does not suppress cough. Smoking irritates the bronchial tree, causing coughing. Nicotine does not cause diuresis.

The most common site of aneurysm formation is in the: a) abdominal aorta, just below the renal arteries. b) aortic arch, around the ascending and descending aorta. c) ascending aorta, around the aortic arch. d) descending aorta, beyond the subclavian arteries.

abdominal aorta, just below the renal arteries. About 75% of aneurysms occur in the abdominal aorta, just below the renal arteries (Debakey type I aneurysms). Debakey type II aneurysms occur in the aortic arch around the ascending and descending aorta, whereas Debakey type III aneurysms occur in the descending aorta, beyond the subclavian arteries

The most common site of aneurysm formation is in the: -descending aorta, beyond the subclavian arteries. -ascending aorta, around the aortic arch. -aortic arch, around the ascending and descending aorta. -abdominal aorta, just below the renal arteries.

abdominal aorta, just below the renal arteries. Explanation: About 75% of aneurysms occur in the abdominal aorta, just below the renal arteries (Debarked type I aneurysms). Debarked type II aneurysms occur in the aortic arch around the ascending and descending aorta, whereas Debarked type III aneurysms occur in the descending aorta, beyond the subclavian arteries. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Aneurysms, p. 838.

The nurse is caring for a client recovering from surgery to treat aortoiliac disease. Which assessment findings indicate to the nurse that manual manipulation of the bowel occurred during the surgery? Select all that apply. Coffee-ground emesis Left lower quadrant pain Abdominal distention Liquid bowel movement Absence of bowel sounds

abdominal distention and absence of bowel sounds Explanation: The treatment of aortoiliac disease is essentially the same as that for atherosclerotic PAD. If there is significant aortic disease, the surgical procedure of choice is the aortoiliac graft. If possible, the distal graft is anastomosed to the iliac artery, and the entire surgical procedure is performed within the abdomen. Because of this, abdominal assessment for bowel sounds and paralytic ileus is to be done at least every 8 hours. Abdominal distention and the absence of bowel sounds indicate paralytic ileus. Coffee-ground emesis is an indication of gastrointestinal bleeding which is not associated with surgery to treat aortoiliac disease. A liquid bowel movement may indicate bowel ischemia which is caused by an occlusion of the mesenteric blood supply. Left lower quadrant abdominal pain is not associated with treatment of aortoiliac disease.

The nurse is discussing basic cardiac hemodynamics and explains preload to the client. What nursing intervention will decrease preload?

administration of a vasodilating drug (as ordered by a health care provider) Preload is the amount of blood presented to the ventricles just before systole. Anything that decreases the amount of blood returning to the heart will decrease preload, such as vasodilation or blood pooling in the extremities. Anything that assists in returning blood to the heart (antiembolic stockings) or preventing blood from pooling in the extremities will increase preload.

A nurse is auscultating heart sounds in a group of clients. Which of the following should the nurse identify as an expected variation?

an adolescent who has an S3 heart sound

A client reports pain and cramping in the thigh when climbing stairs and numbness in the legs after exertion. Which diagnostic test with the physician likely perform right in the office to determine PAD? exercise electrocardiography electron beam computed tomography ankle-brachial index photoplethysmography

ankle-brachial index

A client reports pain and cramping in the thigh when climbing stairs and numbness in the legs after exertion. Which diagnostic test with the physician likely perform right in the office to determine PAD? -photoplethysmography -electron beam computed tomography -ankle-brachial index -exercise electrocardiography

ankle-brachial index Explanation: The client's symptoms indicate possible peripheral artery disease (PAD). The ankle-brachial index is a simple, noninvasive test used for this diagnosis. An exercise electrocardiography may be ordered for a client with possible CAD. An EBCT is a radiologic test that produces x-rays of the coronary arteries using an electron beam. It is used to diagnose for CAD. Clients with suspected venous insufficiency will undergo photoplethysmography, a diagnostic test that measures light that is not absorbed by hemoglobin and consequently is reflected back to the machine. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Doppler Ultrasound Flow Studies, p. 824.

The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is contrast phlebography. lymphangiography. air plethysmography. lymphoscintigraphy.

contrast phlebography. Explanation: Also known as venography, contrast phlebography involves injecting a radiopaque contrast agent into the venous system. If a thrombus exists, the x-ray image reveals an unfilled segment of vein in an otherwise completely filled vein. Air plethysmography quantifies venous reflux and calf muscle pump ejection. In lymphangiography, contrast media are injected into the lymph system. In a lymphoscintigraphy, a radioactive-labeled colloid is injected into the lymph system.

The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is lymphoscintigraphy. lymphangiography. air plethysmography. contrast phlebography.

The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is -lymphangiography. -contrast phlebography. -lymphoscintigraphy. -air plethysmography.

contrast phlebography. Explanation: When a thrombus exists, an x-ray image will disclose an unfilled segment of a vein. Air plethysmography quantifies venous reflux and calf muscle pump ejection. In lymphangiography, contrast media are injected into the lymph system. In a lymphoscintigraphy, a radioactive-labeled colloid is injected into the lymph system. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Contrast Phlebography (Venography), p. 826.

A nurse is teaching a client about behaviors that promote cardiovascular health. Which of the following client statements indicate an understanding of the teaching? (SATA)

correct terms: -"I am going to start walking several times a week." -"I plan to join a support group to help me stop smoking." -"I will be sure to have my blood pressure checked at least every year."

A nurse is inspecting and palpating the neck vessels of a client. Which of the following findings should the nurse report to the provider? (SATA)

correct terms: -full, bounding pulse noted bilaterally in the carotid arteries upon palpation -distention of the jugular vein on one side of the neck. -the left carotid artery pulse is weak

A nurse caring for a client recently admitted to the ICU observes the client coughing up large amounts of pink, frothy sputum. Lung auscultation reveals course crackles to lower lobes bilaterally. Based on this assessment, the nurse recognizes this client is developing

decompensated heart failure with pulmonary edema

A client asks the nurse if systolic heart failure will affect any other body function. What body system response correlates with systolic heart failure (HF)?

decrease in renal perfusion A decrease in renal perfusion due to low cardiac output (CO) and vasoconstriction causes the release of renin by the kidney. Systolic HF results in decreased blood volume being ejected from the ventricle. Sympathetic stimulation causes vasoconstriction of the skin, gastrointestinal tract, and kidneys. Dehydration does not correlate with systolic heart failure.

The nurse is admitting a client with frothy pink sputum. What does the nurse suspect is the primary underlying disorder of pulmonary edema?

decreased left ventricular pumping Pulmonary edema is an acute event that results from heart failure. Myocardial scarring, resulting from ischemia, limits the distensibility of the ventricle, making it vulnerable to demands for increased workload. When the demand on the heart increases, there is resistance to left ventricular filling and blood backs up into the pulmonary circulation. Pulmonary edema quickly develops.

The nurse is providing care to a client with cardiogenic shock requiring a intra-aortic balloon pump (IABP). What is the therapeutic effect of the IABP therapy?

decreased left ventricular workload

To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a 45-degree angle and then have the client sit up. The nurse suspects arterial insufficiency if the assessment reveals: a) dependent pallor. b) no rubor for 10 seconds after the maneuver. c) elevational rubor. d) a 30-second filling time for the veins.

dependent pallor. If arterial insufficiency is present, elevation of the limb would yield a pallor from the lack of circulation. Rubor and increased venous filling time would suggest venous problems secondary to venous trapping and incompetent valves.

Frequently, what is the earliest symptom of left-sided heart failure?

dyspnea on exertion

To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a 45-degree angle and then have the client sit up. The nurse suspects arterial insufficiency if the assessment reveals: elevational pallor. elevational rubor. no rubor for 10 seconds after the maneuver. a 30-second filling time for the veins.

elevational pallor.

To check for arterial insufficiency when a client is in a supine position, the nurse should elevate the extremity at a 45-degree angle and then have the client sit up. The nurse suspects arterial insufficiency if the assessment reveals: -elevational rubor. -a 30-second filling time for the veins. -no rubor for 10 seconds after the maneuver. -elevational pallor.

elevational pallor. Explanation: If arterial insufficiency is present, elevation of the limb would yield a pallor from the lack of circulation. Rubor on elevation and increased venous filling time would suggest venous problems secondary to venous trapping and incompetent valves. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Peripheral Artery Disease, p. 835.

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: a) providing warmth to the extremity. b) encouraging ambulation to prevent pooling of blood. c) forcing blood into the deep venous system. d) elevating the extremity to prevent pooling of blood.

forcing blood into the deep venous system. Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn't a function of the stockings. Antiembolism stockings could possibly provide warmth, but this factor isn't how they prevent DVT. Elevating the extremity decreases edema but doesn't prevent DVT.

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: forcing blood into the deep venous system. providing warmth to the extremity. encouraging ambulation to prevent pooling of blood. elevating the extremity to prevent pooling of blood.

forcing blood into the deep venous system. Explanation: Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn't a function of the stockings. Antiembolism stockings could possibly provide warmth, but this factor isn't how they prevent DVT. Elevating the extremity decreases edema but doesn't prevent DVT.

The nurse is teaching a client about medications prescribed for severe volume overload from heart failure. What diuretic is the first-line treatment for clients diagnosed with heart failure?

furosemide

A nurse is administering digoxin. What client parameter would cause the nurse to hold the digoxin and notify the health care prescriber?

heart rate of 55 beats per minute

The nurse is assessing a client with crackling breath sounds or pulmonary congestion. What is the cause of the congestion?

inadequate cardiac output

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should: elevate the affected leg as high as possible. place a heating pad around the affected calf. keep the affected leg level or slightly dependent. shave the affected leg in anticipation of surgery.

keep the affected leg level or slightly dependent.

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should: a) shave the affected leg in anticipation of surgery. b) keep the affected leg level or slightly dependent. c) elevate the affected leg as high as possible. d) place a heating pad around the affected calf.

keep the affected leg level or slightly dependent. While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg could cause accidental trauma from cuts or nicks.

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should: -keep the affected leg level or slightly dependent. -shave the affected leg in anticipation of surgery. -elevate the affected leg as high as possible. -place a heating pad around the affected calf.

keep the affected leg level or slightly dependent. Explanation: While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg could cause accidental trauma from cuts or nicks. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Anatomic and Physiologic Overview, p. 820.

Vasodilation or vasoconstriction produced by an external cause will interfere with a nurse's accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should: a) maintain room temperature at 78° F (25.6° C). b) keep the client uncovered. c) match the room temperature to the client's body temperature. d) keep the client warm.

keep the client warm. The nurse should keep the client covered and expose only the portion of the client's body that she's assessing. The nurse should also keep the client warm by maintaining his room temperature between 68° F and 74° F (20° and 23.3° C). Extreme temperatures aren't good for clients with PVD. The valves in their arteries and veins are already insufficient, and exposing them to vast changes in temperature could affect assessment findings. Keeping the client uncovered would cause him to become chilled. Matching the room temperature to the client's body temperature is inappropriate.

Vasodilation or vasoconstriction produced by an external cause will interfere with a nurse's accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should: -maintain room temperature at 78° F (25.6° C). -match the room temperature to the client's body temperature. -keep the client uncovered. -keep the client warm. SUBMIT ANSWER

keep the client warm. Explanation: The nurse should keep the client covered and expose only the portion of the client's body that she's assessing. The nurse should also keep the client warm by maintaining his room temperature between 68° F and 74° F (20° and 23.3° C). Extreme temperatures aren't good for clients with PVD. The valves in their arteries and veins are already insufficient, and exposing them to vast changes in temperature could affect assessment findings. Keeping the client uncovered would cause him to become chilled. Matching the room temperature to the client's body temperature is inappropriate. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Peripheral Artery Disease, p. 834.

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect: left calf circumference 1" (2.5 cm) larger than the right. a decrease in the left pedal pulse. pallor and coolness of the left foot. loss of hair on the lower portion of the left leg.

left calf circumference 1" (2.5 cm) larger than the right.

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect: a) loss of hair on the lower portion of the left leg. b) left calf circumference 1" (2.5 cm) larger than the right. c) pallor and coolness of the left foot. d) a decrease in the left pedal pulse.

left calf circumference 1" (2.5 cm) larger than the right. Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased pulse, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT.

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect: -pallor and coolness of the left foot. -a decrease in the left pedal pulse. -loss of hair on the lower portion of the left leg. -left calf circumference 1" (2.5 cm) larger than the right.

left calf circumference 1" (2.5 cm) larger than the right. Explanation: Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased pulse, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT. Reference: Hinkle, J.L., & Cheever, K.H., Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th ed., Philadelphia, Wolters Kluwer, 2022, Chapter 26: Assessment and Management of Patients with Vascular Disorders and Disorders of Peripheral Circulation, Contrast Phlebography (Venography), p. 826.

The nurse is administering digoxin to a client with heart failure. What laboratory value may predispose the client to digoxin toxicity?

potassium level of 2.8 mEq/L

Which term describes the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole?

preload Preload is the degree of stretch of the ventricular cardiac muscle fibers at the end of diastole. Afterload is the amount of resistance to ejection of blood from a ventricle. The ejection fraction is the percentage of blood volume in the ventricles at the end of diastole that is ejected during systole. Stroke volume is the amount of blood pumped out of the ventricle with each contraction.

A nurse is completing a medical history on a client. Which of the following findings indicates the client has a family history of cardiovascular disease?

sibling has hypertension

Which of the following are indications of a rupturing aortic aneurysm? Select all that apply. a) Decreasing hematocrit b) Increasing hematocrit c) Decreasing blood pressure d) Increasing blood pressure e) Constant, intense back pain

• Decreasing hematocrit • Decreasing blood pressure • Constant, intense back pain Indications of a rupturing abdominal aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit.

A client with chronic heart failure is receiving digoxin 0.25 mg by mouth daily and furosemide 20 mg by mouth twice daily. The nurse should assess the client for what sign of digoxin toxicity?

visual disturbances Digoxin toxicity may cause visual disturbances (e.g., flickering flashes of light, colored or halo vision, photophobia, blurring, diplopia, and scotomata), central nervous system abnormalities (e.g., headache, fatigue, lethargy, depression, irritability and, if profound, seizures, delusions, hallucinations, and memory loss), and cardiovascular abnormalities (e.g., abnormal heart rate, arrhythmias). Digoxin toxicity doesn't cause taste and smell alterations. Dry mouth and urine retention typically occur with anticholinergic agents, not inotropic agents such as digoxin. Nocturia and sleep disturbances are adverse effects of furosemide — especially if the client takes the second daily dose in the evening, which may cause diuresis at night.

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