Chapter 36: Care of Patients with Vascular Problems: Medical-Surgical Nursing, 8th Edition

Question 1

1. A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene?
   a. Assessing blood pressure in both upper extremities
   b. Auscultating the carotid arteries for any bruits
   c. Classifying capillary refill of 4 seconds as normal
   d. Palpating both carotid arteries at the same time

Answer 1

d. Palpating both carotid arteries at the same time

Question 2

2. The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning?
   a. Cholesterol: 126 mg/dL
   b. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL
   c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL
   d. Triglycerides: 198 mg/dL

Answer 2

d. Triglycerides: 198 mg/dL

Question 3

3. The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet?
   a. A 4-ounce steak, French fries, iceberg lettuce
   b. Baked chicken breast, broccoli, tomatoes
   c. Fried catfish, cornbread, peas
   d. Spaghetti with meat sauce, garlic bread

Answer 3

b. Baked chicken breast, broccoli, tomatoes

Question 4

4. A nurse is working with a client who takes atorvastatin (Lipitor). The clients recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best?
   a. Ask if the client eats grapefruit.
   b. Assess the client for dehydration.
   c. Facilitate admission to the hospital.
   d. Obtain a random urinalysis.

Answer 4

a. Ask if the client eats grapefruit.

Question 5

5. A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?
   a. Do you have trouble affording your medications?
   b. Most people with hypertension do not have symptoms.
   c. You are lucky; most people get severe morning headaches.
   d. You need to take your medicine or you will get kidney failure.

Answer 5

b. Most people with hypertension do not have symptoms.

Question 6

6. A student nurse asks what essential hypertension is. What response by the registered nurse is best?
   a. It means it is caused by another disease.
   b. It means it is essential that it be treated.
   c. It is hypertension with no specific cause.
   d. It refers to severe and life-threatening hypertension.

Answer 6

c. It is hypertension with no specific cause.

Question 7

7. A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service?
   a. African-American churches
   b. Asian-American groceries
   c. High school sports camps
   d. Womens health clinics

Answer 7

a. African-American churches

Question 8

8. A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best?
   a. Assess the clients support system.
   b. Assist in finding one change the client can control.
   c. Determine what stressors the client faces in daily life.
   d. Inquire about delegating some of the clients obligations

Answer 8

b. Assist in finding one change the client can control.

Question 9

9. The nurse is caring for four hypertensive clients. Which druglaboratory value combination should the nurse report immediately to the health care provider?
   a. Furosemide (Lasix)/potassium: 2.1 mEq/L
   b. Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L
   c. Spironolactone (Aldactone)/potassium: 5.1 mEq/L
   d. Torsemide (Demadex)/sodium: 142 mEq/L

Answer 9

a. Furosemide (Lasix)/potassium: 2.1 mEq/L

Question 10

10. A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information?
    a. Could you walk further than that a few months ago?
    b. Do you walk mostly uphill, downhill, or on flat surfaces?
    c. Have you ever considered swimming instead of walking?
    d. How much pain medication do you take each day?

Answer 10

a. Could you walk further than that a few months ago?

Question 11

11. An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care?
    a. I nearly always wear comfy sweatpants and house shoes.
    b. Im glad I get energy assistance so my house isnt so cold.
    c. My daughter makes sure I have plenty of lotion for my feet.
    d. My hands shake when I try to do things requiring coordination.

Answer 11

d. My hands shake when I try to do things requiring coordination.

Question 12

12. A client is taking warfarin (Coumadin) and asks the nurse if taking St. Johns wort is acceptable. What response by the nurse is best?
    a. No, it may interfere with the warfarin.
    b. There isnt any information about that.
    c. Why would you want to take that?
    d. Yes, it is a good supplement for you.

Answer 12

a. No, it may interfere with the warfarin.

Question 13

13. A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best?
    a. No, women should only have one beer a day as a general rule.
    b. No, you should not drink any alcohol with hypertension.
    c. Yes, since you are larger, you can have more alcohol.
    d. Yes, two beers per day is an acceptable amount of alcohol.

Answer 13

a. No, women should only have one beer a day as a general rule.

Question 14

14. A nurse is caring for four clients. Which one should the nurse see first?
    a. Client who needs a beta blocker, and has a blood pressure of 92/58 mm Hg
    b. Client who had a first dose of captopril (Capoten) and needs to use the bathroom
    c. Hypertensive client with a blood pressure of 188/92 mm Hg
    d. Client who needs pain medication prior to a dressing change of a surgical wound

Answer 14

b. Client who had a first dose of captopril (Capoten) and needs to use the bathroom

Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose

Question 15

15. A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met?
    a. Pain rated as 2/10 after medication
    b. Distal pulse on affected extremity 2+/4+
    c. Remains on bedrest as directed
    d. Verbalizes understanding of procedure

Answer 15

b. Distal pulse on affected extremity 2+/4+

Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4+ indicates good perfusion

Question 16

16. A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority?
    a. Administer pain medication as ordered.
    b. Assess distal pulses and skin color.
    c. Document the findings in the clients chart.
    d. Notify the surgeon immediately.

Answer 16

b. Assess distal pulses and skin color.

The nurse should assess for other signs of perfusion, such as distal pulses and skin color/temperature

Question 17

17. A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection?
    a. Appropriate hand hygiene before giving care
    b. Assessing the clients temperature every 4 hours
    c. Clean technique when changing dressings
    d. Monitoring the clients daily white blood cell count

Answer 17

a. Appropriate hand hygiene before giving care

Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes should be done with sterile technique. Assessing vital signs and white blood cell count will not prevent infection.

Question 18

18. A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority?
    a. Assess the clients neurologic status.
    b. Notify the Rapid Response Team.
    c. Prepare to administer vitamin K.
    d. Turn down the infusion rate.

Answer 18

b. Notify the Rapid Response Team.

Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic signs may indicate the client is having a hemorrhagic stroke. The nurse does need to complete a thorough neurological examination, but should first call the Rapid Response Team based on the clients manifestations. The nurse notifies the Rapid Response Team first

Question 19

19. A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene?
    a. Assesses the client for back pain
    b. Auscultates over abdominal bruit
    c. Measures the abdominal girth
    d. Palpates the abdomen in four quadrants

Answer 19

d. Palpates the abdomen in four quadrants

Abdominal aneurysms should never be palpated as this increases the risk of rupture. The registered nurse should intervene when the student attempts to do this.

Question 20

20. A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met?
    a. Ambulates with assistance
    b. Oxygen saturation of 98%
    c. Pain of 2/10 after medication
    d. Verbalizing risk factors

Answer 20

b. Oxygen saturation of 98%

A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred

Question 21

21. A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?
    a. Ambulate the client.
    b. Apply a warm moist pack.
    c. Massage the clients leg.
    d. Provide an ice pack.

Answer 21

b. Apply a warm moist pack.

Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the clients legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.

Question 22

22. A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best?
    a. Ask if the weight loss was intended.
    b. Encourage a high-protein, high-fiber diet.
    c. Measure for new compression stockings.
    d. Review a 3-day food recall diary.

Answer 22

c. Measure for new compression stockings.

Compression stockings must fit correctly in order to work. After losing a significant amount of weight, the client should be re-measured and new stockings ordered if needed. The other options are appropriate, but not the most important.

Question 23

23. A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal?

a. Teach high school students heart-healthy living.
b. Participate in blood pressure screenings at the mall.
c. Provide pamphlets on heart disease at the grocery store.
d. Set up an Ask the nurse booth at the pet store.c. Provide pamphlets on heart disease at the grocery store.
d. Set up an Ask the nurse booth at the pet store.

Answer 23

b. Participate in blood pressure screenings at the mall.

Question 24

24. A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin (Coumadin). The client is adamant about refusing the drug because its dangerous. What action by the nurse is best?
    a. Assess the reason behind the clients fear.
    b. Remind the client about laboratory monitoring.
    c. Tell the client drugs are safer today than before.
    d. Warn the client about consequences of noncompliance.

Answer 24

a. Assess the reason behind the clients fear.

The first step is to assess the reason behind the clients fear, which may be related to the experience of someone the client knows who took warfarin

Question 25

25. A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril (Prinivil) and warfarin (Coumadin). The client reports new-onset cough. What action by the nurse is most appropriate? a. Assess the clients lung sounds and oxygenation. b. Instruct the client on another antihypertensive. c. Obtain a set of vital signs and document them. d. Remind the client that cough is a side effect of Prinivil.

Answer 25

a. Assess the clients lung sounds and oxygenation.

Question 26

26. A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best? a. Consult with the Wound Ostomy Care Nurse. b. Give pain medication prior to dressing changes. c. Maintain sterile technique for dressing changes. d. Prepare the client for eventual amputation.

Answer 26

a. Consult with the Wound Ostomy Care Nurse.

Question 27

27. A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? a. I can use a heating pad on my legs if its set on low. b. I should not cross my legs when sitting or lying down. c. I will go out and buy some warm, heavy socks to wear. d. Its going to be really hard but I will stop smoking

Answer 27

a. I can use a heating pad on my legs if its set on low. Clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result. The other statements show good understanding of self-management.

Question 28

28. A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse? a. Administer oxygen via non-rebreather mask. b. Ensure the client has a patent airway. c. Prepare to assist with suturing the artery. d. Start two large-bore IVs with normal saline.

Answer 28

b. Ensure the client has a patent airway.

Question 29

29. The nurse is assessing a client on admission to the hospital. The clients leg appears as shown below: What action by the nurse is best? a. Assess the clients ankle-brachial index. b. Elevate the clients leg above the heart. c. Obtain an ice pack to provide comfort. d. Prepare to teach about heparin sodium.

Answer 29

a. Assess the clients ankle-brachial index.

Question 30

1. What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.) a. Administering mild analgesics for pain b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises e. Teaching the client about surgical options

Answer 30

b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises

Question 31

2. A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Administering preoperative medication b. Ensuring the consent is signed c. Marking pulses with a pen d. Raising the siderails on the bed e. Recording baseline vital signs

Answer 31

d. Raising the siderails on the bed | e. Recording baseline vital signs

Question 32

3. A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention? (Select all that apply.) a. Apply compression stockings. b. Assist with ambulation. c. Encourage coughing and deep breathing. d. Offer fluids frequently. e. Teach leg exercises.

Answer 32

a. Apply compression stockings. b. Assist with ambulation. d. Offer fluids frequently.

Question 33

4. A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the clients plan of care? (Select all that apply.) a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. c. Stop the IV for aPTT above baseline. d. Use an IV pump for the infusion. e. Weigh the client daily on the same scale.

Answer 33

a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. d. Use an IV pump for the infusion.

Question 34

5. A client is being discharged on warfarin (Coumadin) therapy. What discharge instructions is the nurse required to provide? (Select all that apply.) a. Dietary restrictions b. Driving restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication

Answer 34

a. Dietary restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication

Question 35

6. Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.) a. A good abrasive pumice stone will keep my feet soft. b. Ill always wear shoes if I can buy cheap flip-flops. c. I will keep my feet dry, especially between the toes. d. Lotion is important to keep my feet smooth and soft. e. Washing my feet in room-temperature water is best.

Answer 35

c. I will keep my feet dry, especially between the toes. d. Lotion is important to keep my feet smooth and soft. e. Washing my feet in room-temperature water is best.

Question 36

7. A nurse is caring for a client with a nonhealing arterial ulcer. The physician has informed the client about possibly needing to amputate the clients leg. The client is crying and upset. What actions by the nurse are best? (Select all that apply.) a. Ask the client to describe his or her current emotions. b. Assess the client for support systems and family. c. Offer to stay with the client if he or she desires. d. Relate how smoking contributed to this situation. e. Tell the client that many people have amputations.

Answer 36

a. Ask the client to describe his or her current emotions. b. Assess the client for support systems and family. c. Offer to stay with the client if he or she desires

Question 37

8. The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply.) a. Atherosclerosis b. Down syndrome c. Frequent heartburn d. History of hypertension e. History of smoking

Answer 37

a. Atherosclerosis d. History of hypertension e. History of smoking

Question 38

9. A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the clients blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.) a. Administer pain medication. b. Assess distal pulses every 10 minutes. c. Have the client sign a surgical consent. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes.

Answer 38

b. Assess distal pulses every 10 minutes. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes.

Question 39

1. A nurse is caring for a client who weighs 220 pounds and is started on enoxaparin (Lovenox). How much enoxaparin does the nurse anticipate administering? (Record your answer using a whole number.) _____ mg

Answer 39

90 mg The dose of enoxaparin is 1 mg/kg body weight, not to exceed 90 mg. This client weighs 220 pounds (110 kg), and so will get the maximal dose.