Chapter 36 Flashcards
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?
Palpating both carotid arteries at the same time
The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning?
Triglycerides: 198 mg/dL
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?
Baked chicken breast, broccoli, tomatoes
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?
Ask if the client eats grapefruit.
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?
“Most people with hypertension do not have symptoms.”
A student nurse asks what “essential hypertension” is. What response by the registered nurse is best?
“It is hypertension with no specific cause.”
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?
African-American churches
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?
Assist in finding one change the client can control.
The nurse is caring for four hypertensive clients. Which drug–laboratory value combination should the nurse report immediately to the health care provider?
Furosemide (Lasix)/potassium: 2.1 mEq/L
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?
“Could you walk further than that a few months ago?”
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?
“My hands shake when I try to do things requiring coordination.”
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?
“No, it may interfere with the warfarin.”
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?
“No, women should only have one beer a day as a general rule.”
A nurse is caring for four clients. Which one should the nurse see first?
Client who had a first dose of captopril (Capoten) and needs to use the bathroom
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?
Distal pulse on affected extremity 2+/4+
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?
Assess distal pulses and skin color.
A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection?
Appropriate hand hygiene before giving care
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?
Notify the Rapid Response Team.
A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene?
Palpates the abdomen in four quadrants
A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met?
Oxygen saturation of 98%
A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?
Apply a warm moist pack.
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?
Measure for new compression stockings.
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?
Participate in blood pressure screenings at the mall.
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?
Assess the reason behind the client’s fear.
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?
Assess the client’s lung sounds and oxygenation.
A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best?
Consult with the Wound Ostomy Care Nurse.
A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities?
“I can use a heating pad on my legs if it’s set on low.”
A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse?
Ensure the client has a patent airway.
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?
Assess the client’s ankle-brachial index.
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
B, C, D
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
D,E
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.
A,B,D
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.
A,B,D
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
A,C,D,E
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.”
C,D,E
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.
A,B,C
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
A,D,E
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.
B,D,E
