Chapter 36

Question 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?

Answer 1

Palpating both carotid arteries at the same time

Question 2

The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning?

Answer 2

Triglycerides: 198 mg/dL

Question 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?

Answer 3

Baked chicken breast, broccoli, tomatoes

Question 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?

Answer 4

Ask if the client eats grapefruit.

Question 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?

Answer 5

“Most people with hypertension do not have symptoms.”

Question 6

A student nurse asks what “essential hypertension” is. What response by the registered nurse is best?

Answer 6

“It is hypertension with no specific cause.”

Question 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?

Answer 7

African-American churches

Question 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?

Answer 8

Assist in finding one change the client can control.

Question 9

The nurse is caring for four hypertensive clients. Which drug–laboratory value combination should the nurse report immediately to the health care provider?

Answer 9

Furosemide (Lasix)/potassium: 2.1 mEq/L

Question 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?

Answer 10

“Could you walk further than that a few months ago?”

Question 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?

Answer 11

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

Question 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?

Answer 12

“No, it may interfere with the warfarin.”

Question 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?

Answer 13

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

Question 14

A nurse is caring for four clients. Which one should the nurse see first?

Answer 14

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

Question 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?

Answer 15

Distal pulse on affected extremity 2+/4+

Question 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?

Answer 16

Assess distal pulses and skin color.

Question 17

A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection?

Answer 17

Appropriate hand hygiene before giving care

Question 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?

Answer 18

Notify the Rapid Response Team.

Question 19

A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene?

Answer 19

Palpates the abdomen in four quadrants

Question 20

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met?

Answer 20

Oxygen saturation of 98%

Question 21

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?

Answer 21

Apply a warm moist pack.

Question 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?

Answer 22

Measure for new compression stockings.

Question 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?

Answer 23

Participate in blood pressure screenings at the mall.

Question 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?

Answer 24

Assess the reason behind the client’s fear.

Question 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?

Answer 25

Assess the client’s lung sounds and oxygenation.

Question 26

A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best?

Answer 26

Consult with the Wound Ostomy Care Nurse.

Question 27

A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities?

Answer 27

“I can use a heating pad on my legs if it’s set on low.”

Question 28

A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse?

Answer 28

Ensure the client has a patent airway.

Question 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?

Answer 29

Assess the client’s ankle-brachial index.

Question 30

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

Question 31

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

Question 32

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

Question 33

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

Question 34

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

Question 35

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

Question 36

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

Question 37

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

Question 38

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