vSIMS #6 Questions

The nurse is caring for a patient who is experiencing physical immobility related to an acute illness. A priority nursing assessment would be to monitor the patient for which of the following? a. Deep vein thrombosis b. Joint contractures c. Constipation d. Exertional dyspnea

a. Deep vein thrombosis

The nurse is performing a peripheral vascular assessment on a patient and notes cramping pain, redness, and warmth in the left lower extremity. The nurse recognizes these clinical manifestations as most likely related to which of the following? a. Deep vein thrombosis b. Arterial occlusion c. Fluid volume overload d. Complication of diabetes mellitus

a. Deep vein thrombosis

The nurse is aware that a nursing diagnosis for Mona Hernandez is impaired physical mobility. The nurse would evaluate the patient for which of the following complications related to impaired mobility? (select all that apply) a. Pressure ulcers b. Deep vein thrombosis c. Atelectasis d. Hypertension e. Candida infections

a. Pressure ulcers b. Deep vein thrombosis c. Atelectasis

The nurse is performing a peripheral vascular assessment on the lower extremities of a patient with 4+ edema of the left foot. The nurse is unable to palpate a dorsalis pedis pulse. Which is the best initial response by the nurse? a. Use a Doppler ultrasound device to detect the pulse b. Call the health provider and report a loss of pulse in the foot c. Take the patient's blood pressure d. Elevate the foot and attempt to palpate the pulse again

a. Use a Doppler ultrasound device to detect the pulse

The nurse is providing education to a hospitalized patient on methods to prevent peripheral vascular complications. Which would the nurse include? (select all that apply) a. You may have to take an anticoagulant by injection b. Avoid prolonged sitting with your legs in a dependent position c. Avoid crossing your legs d. Wear comfortable cotton socks and shoes when ambulating e. Perform active range-of-motion exercises of your feet and ankles while in bed f. Practice relaxation techniques to reduce stress and pain

a. You may have to take an anticoagulant by injection b. Avoid prolonged sitting with your legs in a dependent position c. Avoid crossing your legs e. Perform active range-of-motion exercises of your feet and ankles while in bed

Which of the following non-pharmacologic interventions is most important for the nurse to initiate to prevent deep vein thrombosis from developing in hospitalized patients? a. Apply warm compresses b. Apply sequential compression stockings c. Perform range-of-motion exercises d. Elevate the legs

b. Apply sequential compression stockings

Components of a peripheral vascular assessment include which of the following? (select all that apply) a. Palpation of bones and joints b. Palpation of feet and legs for temperature c. Auscultation of popliteal pulses d. Palpation of the posterior tibial pulses e. Inspection and palpation for edema f. Inspection for lesions or ulcers

b. Palpation of feet and legs for temperature d. Palpation of the posterior tibial pulses e. Inspection and palpation for edema f. Inspection for lesions or ulcers

A patient reports a new onset of leg pain. Which of the following assessment would the nurse perform first? a. Inspect the feet and legs for the presence of lesions b. Assess the patient's ability to bear weight on the affected leg c. Ask the patient specific questions about the pain d. Palpate the legs for areas of warmth and tenderness

c. Ask the patient specific questions about the pain

The nurse is performing a peripheral vascular assessment on the lower extremities of a patient diagnosed with diabetes. Which assessment is important for the nurse to include? a. Measure degree of knee flexion b. Assess patellar reflexes c. Palpate dorsalis pedis pulse d. Inspect nails for fungal growth

c. Palpate dorsalis pedis pulse

The nurse is preparing to call the health care provider regarding Mona Hernandez's new onset of redness, swelling, and pain in the lower left extremity. In addition to using SBAR format in communication, which of the following is most important for the nurse to do to prevent communication errors when telephoning the health care provider about the patient's change in condition? a. Call the health care provider in the presence of the patient or family member b. Notify the nursing supervisor that the health care provider is being notified c. Write down and read back any orders received or information shared d. Document assessment findings before notifying the health care provider

c. Write down and read back any orders received or information shared

The nurse is assessing a patient for clinical manifestations of venous insufficiency. Which of the following is a characteristic of venous insufficiency? a. Dry, shiny skin b. Nails thickened and ridged c. Cool-to-cold temperature d. Aching, cramping pain

d. Aching, cramping pain

The nurse has provided patient education to Mona Hernandez and explained the blood tests and procedures that were ordered. Which of the following would be important additional education to provide to the patient in relation to deep vein thrombosis? a. Discuss the importance of maintaining normal blood glucose levels b. Demonstrate the use of the incentive spirometer c. Discuss the importance of increasing vitamin K intake d. Explain the importance of reporting worsening calf pain, chest pain, edema or dyspnea

d. Explain the importance of reporting worsening calf pain, chest pain, edema or dyspnea

Which of the following is a factor that increases the risk for deep vein thrombosis for Mona Hernandez? a. Age b. Diagnosis of pneumonia c. History of smoking d. Immobility

d. Immobility

Which nursing diagnoses would the nurse identify as the priority for Mona Hernandez based on her assessment findings? a. Risk for infection b. Risk for impaired skin integrity c. Impaired gas exchange d. Ineffective peripheral tissue perfusion

d. Ineffective peripheral tissue perfusion

The nurse is caring for a patient who has developed a deep vein thrombosis in the left lower extremity. Which are appropriate nursing interventions to implement for a patient with deep vein thrombosis? (select all that apply) a. Provide prescribed pain medication as needed and monitor effects b. Perform regular assessments on the affected leg for changes in color, pulses, pain or sensation c. Limit food and fluid intake until the clot is dissolved d. Apply antiembolism elastic compression stockings or sequential compression devices e. Administer anticoagulants and oxygen therapy as prescribed, and monitor effects f. Apply cold compresses to both legs every 4 hours

a. Provide prescribed pain medication as needed and monitor effects b. Perform regular assessments on the affected leg for changes in color, pulses, pain or sensation e. Administer anticoagulants and oxygen therapy as prescribed, and monitor effects

The nurse is performing an assessment of the peripheral vascular system and notes edema in one of the lower extremities. Which are causes of unilateral edema of the lower extremities? a. Prolonged presence of a cast on the extremity b. Venous stasis and obstruction c. Congestive heart failure d. Prolonged standing position

b. Venous stasis and obstruction

Based on the initial patient data, Mona Hernandez's report of pain, and physical assessment findings, the nurse performs a focused respiratory status on the patient. In addition to the patient's diagnosis of pneumonia, the nurse recognizes which of the following as the most important rationale for assessing the patient's respiratory status? a. A history of smoking is a risk factor for peripheral arterial disease b. Respiratory assessment will determine the presence of bacterial infection c. A serious complication of deep vein thrombosis is pulmonary embolus d. The patient's VS and SpO2 levels indicated a decline in physical status

c. A serious complication of deep vein thrombosis is pulmonary embolus

The nurse is preparing to perform a peripheral vascular assessment on a patient with an ulcer on the right foot. Which general principle of physical assessment is most important for the nurse to remember in performing a peripheral vascular assessment? a. Ensure that the stethoscope is warmed before using b. Have the patient stand upright for the physical assessment c. Always compare arms and legs bilaterally d. Palpate for skin temperature using the fingertips

c. Always compare arms and legs bilaterally