Ch 36 Vascular Disease

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

The student should not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure
should be taken and compared in both arms. Prolonged capillary refill is considered to be greater than 5 seconds in
an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits should be
auscultate

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 in men should be below 160 mg/dL. The other values are appropriate for adult males.

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

The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole
grains (fiber), low in salt, and low in trans fat. The best choice is the chicken with broccoli and tomatoes. The
French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has
too much red meat and no vegetables.

Question 4

4. A nurse is working with a client who takes atorvastatin (Lipitor). The client’s 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

There is a drug-food interaction between statins and grapefruit that can lead to acute kidney failure. This client has
elevated renal laboratory results, indicating some degree of kidney involvement. The nurse should assess if the client
eats grapefruit or drinks grapefruit juice. Dehydration can cause the BUN to be elevated, but the elevation in
creatinine is more specific for a kidney injury. The client does not necessarily need to be admitted. A urinalysis may
or may not be ordered.

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 are asymptomatic, although a small percentage do have symptoms such as headache.
The nurse should explain this to the client. Asking about paying for medications is not related because the client has
already admitted nonadherence. Threatening the client with possible complications will not increase compliance.

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

Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying
disease process. Hypertension that is due to another disease process is called secondary hypertension. A severe,
life-threatening form of hypertension is malignant hypertension.

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. Women’s health clinics

Answer 7

A
African Americans in the United States have one of the highest rates of hypertension in the world. The nurse has the
potential to reach this priority population by providing services at African-American churches. Although
hypertension education and screening are important for all groups, African Americans are the priority population for
this intervention.

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 client’s 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 client’s obligations.

Answer 8

B
All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by
the suggested lifestyle changes. Instead of looking at all the needed changes, the nurse should assist the client in
choosing one the client feels optimistic about controlling. Once the client has mastered that change, he or she can
move forward with another change. Determining support systems, daily stressors, and delegation opportunities does
not directly impact the client’s feelings of control.

Question 9

9. The nurse is caring for four hypertensive clients. Which drug–laboratory 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
Lasix is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and should be
reported immediately. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. A potassium
level of 5.1 mEq/L is on the high side, but it is not as critical as the low potassium with furosemide. The other two
laboratory values are normal.

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

As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain free
indicates the client’s disease is worsening. The other questions are useful, but not as important.

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. “I’m glad I get energy assistance so my house isn’t 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
Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across.
The client whose hands shake may cause injury when trimming toenails. The nurse should refer this client to a
podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for clients
with PVD. Keeping the house at a comfortable temperature makes it less likely the client will use alternative heat
sources, such as heating pads, to stay warm. The client should keep the feet moist and soft with lotion.

Question 12

12. A client is taking warfarin (Coumadin) and asks the nurse if taking St. John’s wort is acceptable. What response
    by the nurse is best?

a. “No, it may interfere with the warfarin.”
b. “There isn’t any information about that.”
c. “Why would you want to take that?”
d. “Yes, it is a good supplement for you.”

Answer 12

A

Many foods and drugs interfere with warfarin, St. John’s wort being one of them. The nurse should advise the client
against taking it. The other answers are not accurate.

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

Alcohol intake should be limited to two drinks a day for men and one drink a day for women. A “drink” is classified
as one beer, 1.5 ounces of hard liquor, or 5 ounces of wine. Limited alcohol intake is acceptable with hypertension.
The woman’s size does not matter.

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

Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose.
The nurse should see this client first to prevent falling if the client decides to get up without assistance. The two
blood pressure readings are abnormal but not critical. The nurse should check on the client with higher blood
pressure next to assess for problems related to the reading. The nurse can administer the beta blocker as standards
state to hold it if the systolic blood pressure is below 90 mm Hg. The client who needs pain medication prior to the
dressing change is not a priority over client safety and assisting the other client to the bathroom.

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
Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4+ indicates good
perfusion. Pain control, remaining on bedrest as directed after the procedure, and understanding are all important,
but do not take priority over 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 client’s chart.
d. Notify the surgeon immediately.

Answer 16

B
Once perfusion has been restored or improved to an extremity, clients can often feel a throbbing pain due to the
increased blood flow. However, it is important to differentiate this pain from ischemia. The nurse should assess for
other signs of perfusion, such as distal pulses and skin color/temperature. Administering pain medication is done
once the nurse determines the client’s perfusion status is normal. Documentation needs to be thorough. Notifying the
surgeon is not necessary.

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 client’s temperature every 4 hours
c. Clean technique when changing dressings
d. Monitoring the client’s daily white blood cell count

Answer 17

A
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 client’s neurologic status.
b. Notify the Rapid Response Team.
c. Prepare to administer vitamin K.
d. Turn down the infusion rate.

Answer 18

B

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 client’s manifestations. The nurse notifies the Rapid
Response Team first. Vitamin K is not the antidote for this drug. Turning down the infusion rate will not be helpful
if the client is still receiving any of the drug.

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

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. The other actions are appropriate.

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

A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not
occurred. The other assessments are also positive, but not the priority.

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 client’s leg.
d. Provide an ice pack.

Answer 21

B

Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the client’s
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

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.

Answer 23

B

An important goal of HP2020 is to increase the proportion of adults who have had their blood pressure measured
within the preceding 2 years and can state whether their blood pressure was normal or high. Participating in blood
pressure screening in a public spot will best help meet that goal. The other options are all appropriate but do not
specifically help meet a goal.

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 “it’s dangerous.” What action by the nurse is best?

a. Assess the reason behind the client’s 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
The first step is to assess the reason behind the client’s fear, which may be related to the experience of someone the
client knows who took warfarin. If the nurse cannot address the specific rationale, teaching will likely be
unsuccessful. Laboratory monitoring once every few weeks may not make the client perceive the drug to be safe.
General statements like “drugs are safer today” do not address the root cause of the problem. Warning the client
about possible consequences of not taking the drug is not therapeutic and is likely to lead to an adversarial
relationship.

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 client’s 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

This client could be having an exacerbation of heart failure or be experiencing a side effect of lisinopril (and other
angiotensin-converting enzyme inhibitors). The nurse should assess the client’s lung sounds and other signs of
oxygenation first. The client may or may not need to switch antihypertensive medications. Vital signs and
documentation are important, but the nurse should assess the respiratory system first. If the cough turns out to be a
side effect, reminding the client is appropriate, but then more action needs to be taken.

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

A nonhealing wound needs the expertise of the Wound Ostomy Care Nurse (or Wound Ostomy Continence Nurse).
Premedicating prior to painful procedures and maintaining sterile technique are helpful, but if the wound is not
healing, more needs to be done. The client may need an amputation, but other options need to be tried first.

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 it’s 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. “It’s going to be really hard but I will stop smoking.”

Answer 27

A

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

Airway always takes priority, followed by breathing and circulation. The nurse ensures the client has a patent airway
prior to providing any other care measures.

Question 29

29. The nurse is assessing a client on admission to the hospital. The client’s leg appears as shown below:
    What action by the nurse is best?

a. Assess the client’s ankle-brachial index.
b. Elevate the client’s leg above the heart.
c. Obtain an ice pack to provide comfort.

d. Prepare to teach about heparin sodium.
ANS:

Answer 29

A

This client has dependent rubor, a classic finding in peripheral arterial disease. The nurse should measure the client’s
ankle-brachial index. Elevating the leg above the heart will further impede arterial blood flow. Ice will cause
vasoconstriction, also impeding circulation and perhaps causing tissue injury. Heparin sodium is not the drug of
choice for this condition.

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, C, D

The three E’s of care for varicose veins include elastic compression hose, exercise, and elevation. Mild analgesics are not a nonpharmacologic measure. Teaching about surgical options is not a comfort measure.

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, E

The UAP can raise the siderails of the bed for client safety and take and record the vital signs. Administering
medications, ensuring a consent is on the chart, and marking the pulses for later comparison should be done by the
registered nurse. This is also often done by the postanesthesia care nurse and is part of the hand-off report.

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, B, D

The UAP can apply compression stockings, assist with ambulation, and offer fluids frequently to help prevent DVT.
The UAP can also encourage the client to do pulmonary exercises, but these do not decrease the risk of DVT.
Teaching is a nursing function.

Question 33

4. A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the client’s 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, B, D

Assessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all important safety measures
for heparin to prevent injury from bleeding. The aPTT needs to be 1.5 to 2 times normal in order to demonstrate that
the heparin is therapeutic. Weighing the client is not related.

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, C, D, E

The Joint Commission’s Core Measures state that clients being discharged on warfarin need instruction on follow-up
monitoring, dietary restrictions, drug-drug interactions, and reason for compliance. Driving is typically not
restricted.

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. “I’ll 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, D, E

Good foot care includes appropriate hygiene and injury prevention. Keeping the feet dry; wearing good, comfortable
shoes; using lotion; washing the feet in room-temperature water; and cutting the nails straight across are all
important measures. Abrasive material such as pumice stones should not be used. Cheap flip-flops may not fit well
and won’t offer much protection against injury.

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 client’s 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, B, C

When a client is upset, the nurse should offer self by remaining with the client if desired. Other helpful measures
include determining what and whom the client has for support systems and asking the client to describe what he or
she is feeling. Telling the client how smoking has led to this situation will only upset the client further and will
damage the therapeutic relationship. Telling the client that many people have amputations belittles the client’s
feelings.

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, D, E

Atherosclerosis, hypertension, hyperlipidemia, and smoking are the most common related factors. Down syndrome
and heartburn have no relation to aneurysm formation.

Question 38

9. A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse
   assesses the client’s 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, D, E

This client may have a ruptured/rupturing aneurysm. The nurse should notify the Rapid Response team and perform
frequent client assessments. Giving pain medication will lower the client’s blood pressure even further. The nurse
cannot have the client sign a consent until the physician has explained the procedure.

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.