N232 Final Exam

Question 1

A 55-year-old male client is being admitted to the nursing unit after left femoral popliteal bypass graft. The nurse is completing the initial assessment. What assessment data should alert the nurse to a possible complication?

1.Client is lethargic with respiratory rate of 14 breaths per minute.
2.Client complains of pain along the incision line of 10 on a scale of 10.
3.The dressing has a small area of dark red-brown drainage.
4.The dorsalis pedis and posterior tibia pulses are weak.

Answer 1

4.The dorsalis pedis and posterior tibia pulses are weak.

Question 2

A client has come to the clinic for complaint of leg pain upon ambulation. During the interview, the client states that the pain occurs after the start of ambulation and progressively gets worse. The pain is relieved by sitting. The client also states that the pain is bilateral. After listening to the client describe the pain and the conditions under which the client experiences the pain, the nurse suspects what condition?

1.Arterial leg ulcers
2.Restless legs syndrome (RLS)
3.Deep vein thrombosis
4.Intermittent claudication

Answer 2

4. Intermittent claudication

Question 3

A female client is being discharged to home with a large venous stasis ulcer on her right ankle. The nurse is providing the client with discharge instructions. Which intervention should the nurse incorporate into the education?
1.Place legs in a dependent position at least four times a day for 10 to 15 minutes.
2.Wear long heavy cotton or wool socks to protect the legs when outdoors.
3.Rest in bed with your right foot flat on the bed for several hours a day.
4.Take walks several times a day, incorporating rest periods with your legs elevated.

Answer 3

4. Take walks several times a day, incorporating rest periods with your legs elevated.

Question 4

A patient in has a new diagnosis of peripheral artery disease. Which medications will the nurse plan to include when providing patient teaching about PAD management?
1.Statins (lipid lowering drug)
2.Antibiotics
3.Thrombolytics
4. Anticoagulants/antiplatelet agents.

Answer 4

1.Statins (lipid lowering drug)

4. Anticoagulants/antiplatelet agents.

Question 5

Which topic should the nurse include in patient teaching for a patient with a venous stasis ulcer on the left lower leg?
1.Need to increase carbohydrate intake.
2.Methods of keeping the would area dry.
3.Purpose of prophylactic antibiotic therapy.
4.Application of elastic compression stockings.

Answer 5

4.Application of elastic compression stockings.

Question 6

A 67 year old patient is admitted to the hospital with a diagnosis of venous insufficiency. Which patient statement aligns most with the diagnosis?
A.“I can’t get my shoes on at the end of the day.”
B.“I can’t seem to ever get my feet warm enough.”
C.“I have burning leg pains after I walk two blocks.”
D.“I wake up during the night because my legs hurt.”

Answer 6

A.“I can’t get my shoes on at the end of the day.

Question 7

A 45 year old patient is admitted to the hospital complaining of a new “sharp, tearing” pain to her chest. Based on the quality of her pain, what do you initially suspect?
1.The patient is having a STEMI.
2.The patient is experiencing an aortic aneurysm.
3.The patient has unstable angina.
4.The patient may be having an aortic dissection.

Answer 7

4.The patient may be having an aortic dissection.

Question 8

Which of the following does not contribute to venous thrombus formation?
1. Hypercoagulability
2. Stasis
3. Heart Failure
4. Endothelial damage

Answer 8

3. Heart Failure

Question 9

What are some symptoms of peripheral arterial disorder?

Answer 9

1. Intermittent claudication
2. Paresthesia
3. Dependent rubour
4. Skin change
5. Decreased circulation signs- weak pulse, increase in cap refill time.

Question 10

What is intermittent claudication?

Answer 10

Pain when you are walking. Begins during exercise and ends with rest.

Question 11

Does Intermittent Claudication occur with PAD or PVD?

Answer 11

PAD

Question 12

What is a diagnostic test of PAD?

Answer 12

Ankle Brachial Pressure Index
( take a BP reading at the brachial arm and at the ankle)- determines the severity. The ankle reading is divided by the brachial reading.

Question 13

What are some drug therapy examples for peripheral vascular disease?

Answer 13

1. Antiplatelets (e.g. aspirin)
2. Statins (lower cholesterol)
3. ACE inhibitors (dilate veins which allows for better blood flow).
4. NSAIDs (for pain and inflammation).

Question 14

What are the 6 P’s associated with acute arterial ischemic disorder?

Answer 14

1. Pain
2. Pallor
3. Pulselessness
4. Paresthesia
5. Paralysis
6. Perishingly cold