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.
