TEST 2: The Client with Vascular Disease

Question 1

The Client with Peripheral Vascular Disease
1. The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic
visit. The client, who exercises regularly, reports having pain in the calf during exercise that
disappears at rest. Which of the following findings requires further evaluation?
1. Heart rate 57 bpm.
2. SpO 2 of 94% on room air.
3. Blood pressure 134/82.
4. Ankle-brachial index of 0.65.

Answer 1

1. 4. An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular disease in a client who
      is experiencing intermittent claudication. A Doppler ultrasound is indicated for further evaluation.
      The bradycardic heart rate is acceptable in an athletic client with a normal blood pressure. The SpO 2
      is acceptable; the client has a smoking history.
      CN: Physiological adaptation; CL: Analyze

Question 2

2. A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft.
   The blood pressure has decreased from 124/80 to 94/62. What should the nurse assess first?
3. IV fluid solution.
4. Pedal pulses.
5. Nasal cannula flow rate.
6. Capillary refill.

Answer 2

2. 2. With each set of vital signs, the nurse should assess the dorsalis pedis and posterior tibial
      pulses. The nurse needs to ensure adequate perfusion to the lower extremity with the drop in blood
      pressure. IV fluids, nasal cannula setting, and capillary refill are important to assess; however,
      priority is to determine the cause of drop in blood pressure and that adequate perfusion through the
      new graft is maintained.
      CN: Reduction of risk potential; CL: Analyze

Question 3

3. An overweight client taking warfarin (Coumadin) has dry skin due to decreased arterial blood
   flow. What should the nurse instruct the client to do? Select all that apply.
4. Apply lanolin or petroleum jelly to intact skin.
5. Follow a reduced-calorie, reduced-fat diet.
6. Inspect the involved areas daily for new ulcerations.
7. Instruct the client to limit activities of daily living (ADLs).
8. Use an electric razor to shave.

Answer 3

3. 1, 2, 3, 5. Maintaining skin integrity is important in preventing chronic ulcers and infections.
   The client should be taught to inspect the skin on a daily basis. The client should reduce weight to
   promote circulation; a diet lower in calories and fat is appropriate. Because the client is receiving
   Coumadin, the client is at risk for bleeding from cuts. To decrease the risk of cuts, the nurse should
   suggest that the client use an electric razor. The client with decreased arterial blood flow should be
   encouraged to participate in ADLs. In fact, the client should be encouraged to consult an exercise
   physiologist for an exercise program that enhances the aerobic capacity of the body.
   CN: Health promotion and maintenance; CL: Synthesize

Question 4

4. The nurse is caring for a client with peripheral artery disease who has recently been
   prescribed clopidogrel (Plavix). The nurse understands that more teaching is necessary when the
   client states which of the following:
5. “I should not be surprised if I bruise easier or if my gums bleed a little when brushing my
   teeth.”
6. “It doesn’t really matter if I take this medicine with or without food, whatever works best for
   my stomach.”
7. “I should stop taking Plavix if it makes me feel weak and dizzy.”
8. “The doctor prescribed this medicine to make my platelets less likely to stick together and help
   prevent clots from forming.”

Answer 4

4. 3: Weakness, dizziness, and headache are common adverse effects of Plavix and the client
   should report these to the physician if they are problematic; in order to decrease risk of clot
   formation, Plavix must be taken regularly and should not be stopped or taken intermittently. The main
   adverse effect of Plavix is bleeding, which often occurs as increased bruising or bleeding when
   brushing teeth. Plavix is well absorbed, and while food may help decrease potential gastrointestinal
   upset, Plavix may be taken with or without food. Plavix is an antiplatelet agent used to prevent clot
   formation in clients who have experienced or are at risk for myocardial infarction, ischemic stroke,
   peripheral artery disease, or acute coronary syndrome.
   CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 5

5. A client is receiving Cilostazol (Pletal) for peripheral arterial disease causing intermittent
   claudication. The nurse determines this medication is effective when the client reports which of the
   following?
6. “I am having fewer aches and pains.”
7. “I do not have headaches anymore.”
8. “I am able to walk further without leg pain.”
9. “My toes are turning grayish black in color.”

Answer 5

5. 3. Cilostazol is indicated for management of intermittent claudication. Symptoms usually
      improve within 2 to 4 weeks of therapy. Intermittent claudication prevents clients from walking for
      long periods of time. Cilostazol inhibits platelet aggregation induced by various stimuli andimproving blood flow to the muscles and allowing the client to walk long distances without pain.
      Peripheral arterial disease causes pain mainly of the leg muscles. “Aches and pains” does not specify
      exactly where the pain is occurring. Headaches may occur as a side effect of this drug, and the client
      should report this information to the health care provider. Peripheral arterial disease causes
      decreased blood supply to the peripheral tissues and may cause gangrene of the toes; the drug is
      effective when the toes are warm to the touch and the color of the toes is similar to the color of the
      body.
      CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 6

6. The client admitted with peripheral vascular disease (PVD) asks the nurse why her legs hurt
   when she walks. The nurse bases a response on the knowledge that the main characteristic of PVD is:
7. Decreased blood flow.2. Increased blood flow.
8. Slow blood flow.
9. Thrombus formation.

Answer 6

6. 1. Decreased blood flow is a common characteristic of all PVD. When the demand for oxygen
      to the working muscles becomes greater than the supply, pain is the outcome. Slow blood flow
      throughout the circulatory system may suggest pump failure. Thrombus formation can result from
      stasis or damage to the intima of the vessels.
      CN: Reduction of risk potential; CL: Apply

Question 7

7. The nurse is planning care for a client who is diagnosed with peripheral vascular disease
   (PVD) and has a history of heart failure. The nurse should develop a plan of care that is based on the
   fact that the client may have a low tolerance for exercise related to:
8. Decreased blood flow.
9. Increased blood flow.
10. Decreased pain.
11. Increased blood viscosity.

Answer 7

7. 1. A client with PVD and heart failure will experience decreased blood flow. In this situation,
      low exercise tolerance (oxygen demand becomes greater than the oxygen supply) may be related to
      less blood being ejected from the left ventricle into the systemic circulation. Decreased blood supply
      to the tissues results in pain. Increased blood viscosity may be a component, but it is of much less
      importance than the disease processes.
      CN: Reduction of risk potential; CL: Synthesize

Question 8

8. When assessing the lower extremities of a client with peripheral vascular disease (PVD), the
   nurse notes bilateral ankle edema. The edema is related to:
9. Competent venous valves.
10. Decreased blood volume.
11. Increase in muscular activity.
12. Increased venous pressure.

Answer 8

8. 4. In PVD, decreased blood flow can result in increased venous pressure. The increase in
      venous pressure results in an increase in capillary hydrostatic pressure, which causes a net filtration
      of fluid out of the capillaries into the interstitial space, resulting in edema. Valves often become
      incompetent with PVD. Blood volume is not decreased in this condition. Decreased muscular action
      would contribute to the formation of edema in the lower extremities.
      CN: Reduction of risk potential; CL: Analyz

Question 9

9. The nurse is obtaining the pulse of a client who has had a femoral-popliteal bypass surgery 6
hours ago. (See below) Which assessment provides the most accurate information about the client's
postoperative status?
1.
2.
3.
4.   
(all photos)

Answer 9

9. 4.
   The presence of a strong dorsalis pedis pulse indicates that there is circulation to the extremity
   distal to the surgery indicating that the graft between the femoral and popliteal artery is allowing
   blood to circulate effectively. Answer 1 shows the nurse obtaining the radial pulse; answer 2 shows
   the femoral pulse, which is proximal to the surgery site and will not indicate circulation distal to thesurgery site. Answer 3 shows the nurse obtaining an apical pulse.
   CN: Reduction of risk potential; CL: Analyze

Question 10

10. The nurse is teaching a client about risk factors associated with atherosclerosis and how to
    reduce the risk. Which of the following is a risk factor that the client is not able to modify?
11. Diabetes.
12. Age.
13. Exercise level.
14. Dietary preferences.

Answer 10

10. 2. Age is a nonmodifiable risk factor for atherosclerosis. The nurse instructs the client to
       manage modifiable risk factors such as comorbid diseases (eg, diabetes), activity level, and diet.
       Controlling serum blood glucose levels, engaging in regular aerobic activity, and choosing a diet low
       in saturated fats can reduce the risk of developing atherosclerosis.
       CN: Health promotion and maintenance; CL: Apply

Question 11

11. The nurse is assessing the lower extremities of the client with peripheral vascular disease(PVD). During the assessment, the nurse should expect to find which of the following clinical
    manifestations of PVD? Select all that apply.
12. Hairy legs.
13. Mottled skin.
14. Pink skin.
15. Coolness.
16. Moist skin.

Answer 11

11. 2, 4. Reduction of blood flow to a specific area results in decreased oxygen and nutrients. As
    a result, the skin may appear mottled. The skin will also be cool to the touch. Loss of hair and dry
    skin are other signs that the nurse may observe in a client with PVD of the lower extremities.
    CN: Health promotion and maintenance; CL: Analyze

Question 12

12. The nurse is unable to palpate the client’s left pedal pulses. Which of the following actions
    should the nurse take next?
13. Auscultate the pulses with a stethoscope.
14. Call the physician.
15. Use a Doppler ultrasound device.
16. Inspect the lower left extremity.

Answer 12

12. 3. When pedal pulses are not palpable, the nurse should obtain a Doppler ultrasound device.
       Auscultation is not likely to be helpful if the pulse isn’t palpable. Inspection of the lower extremity
       can be done simultaneously when palpating, but the nurse should first try to locate a pulse by Doppler.
       Calling the physician may be necessary if there is a change in the client’s condition.
       CN: Physiological adaptation; CL: Synthesize

Question 13

13. Which of the following lipid abnormalities is a risk factor for the development of
    atherosclerosis and peripheral vascular disease?
14. Low concentration of triglycerides.
15. High levels of high-density lipid (HDL) cholesterol.
16. High levels of low-density lipid (LDL) cholesterol.
17. Low levels of LDL cholesterol

Answer 13

13. 3. An increased LDL cholesterol concentration has been documented as a risk factor for the
       development of atherosclerosis. LDL cholesterol is not broken down in the liver but is deposited into
       the intima of the blood vessels. Low triglyceride levels are desirable. High HDL and low LDL levels
       are beneficial and are known to be protective for the cardiovascular system.
       CN: Reduction of risk potential; CL: Apply

Question 14

14. When assessing an individual with peripheral vascular disease, which clinical manifestation
    would indicate complete arterial obstruction in the lower left leg?
15. Aching pain in the left calf.
16. Burning pain in the left calf.
17. Numbness and tingling in the left leg.
18. Coldness of the left foot and ankle.

Answer 14

14. 4. Coldness in the left foot and ankle is consistent with complete arterial obstruction. Other
       expected findings would include paralysis and pallor. Aching pain, a burning sensation, or numbness
       and tingling are earlier signs of tissue hypoxia and ischemia and are commonly associated with
       incomplete obstruction.
       CN: Physiological adaptation; CL: Analyze

Question 15

15. A client with peripheral vascular disease returns to the surgical care unit after having
    femoral-popliteal bypass grafting. Indicate in which order the nurse should conduct assessment of this
    client.
16. Postoperative pain.
17. Peripheral pulses.
18. Urine output.
19. Incision site.

Answer 15

15.
2. Peripheral pulses.
4. Incision site.
3. Urine output.
1. Postoperative pain.
Because assessment of the presence and quality of the pedal pulses in the affected extremity is
essential after surgery to make sure that the bypass graft is functioning, this step should be done first.The nurse should next ensure that the dressing is intact, and then that the client has adequate urine
output. Lastly, the nurse should determine the client’s level of pain.
CN: Physiological adaptation; CL: Synthesize

Question 16

16. A client with heart failure has bilateral +4 edema of the right ankle that extends up to midcalf.
    The client is sitting in a chair with the legs in a dependent position. Which of the following goals is
    the priority?
17. Decrease venous congestion.
18. Maintain normal respirations.
19. Maintain body temperature.
20. Prevent injury to lower extremities.

Answer 16

16. 1. Decreasing venous congestion in the extremities is a desired outcome for clients with heart
       failure. The nurse should elevate the client’s legs above the level of the heart to achieve this goal. The
       client is not demonstrating difficulty breathing or being cold. The nurse should prevent injury to the
       swollen extremity; however, this is not the priority.
       CN: Health promotion and maintenance; CL: Synthesize

Question 17

17. The nurse is assessing an older Caucasian male who has a history of peripheral vascular
    disease. The nurse observes that the man’s left great toe is black. The discoloration is probably a
    result of:
18. Atrophy.
19. Contraction.
20. Gangrene.
21. Rubor.

Answer 17

17. 3. The term gangrene refers to blackened, decomposing tissue that is devoid of circulation.
       Chronic ischemia and death of the tissue can lead to gangrene in the affected extremity. Injury, edema,
       and decreased circulation lead to infection, gangrene, and tissue death. Atrophy is the shrinking of
       tissue, and contraction is joint stiffening secondary to disuse. The term rubor denotes a reddish color
       of the skin.
       CN: Physiological adaptation; CL: Analyze

Question 18

18. A client has peripheral vascular disease (PVD) of the lower extremities. The client tells the
    nurse, “I’ve really tried to manage my condition well.” Which of the following routines should the
    nurse evaluate as having been appropriate for this client?
19. Resting with the legs elevated above the level of the heart.
20. Walking slowly but steadily for 30 minutes twice a day.
21. Minimizing activity.
22. Wearing antiembolism stockings at all times when out of bed.

Answer 18

18. 2. Slow, steady walking is a recommended activity for clients with peripheral vascular
       disease because it stimulates the development of collateral circulation. The client with PVD should
       not remain inactive. Elevating the legs above the heart or wearing antiembolism stockings is a
       strategy for alleviating venous congestion and may worsen peripheral arterial disease.
       CN: Basic care and comfort; CL: Evaluate

Question 19

19. A client is scheduled for an arteriogram. The nurse should explain to the client that the
    arteriogram will confirm the diagnosis of occlusive arterial disease by:
20. Showing the location of the obstruction and the collateral circulation.
21. Scanning the affected extremity and identifying the areas of volume changes.
22. Using ultrasound to estimate the velocity changes in the blood vessels.
23. Determining how long the client can walk.

Answer 19

19. 1. An arteriogram involves injecting a radiopaque contrast agent directly into the vascular
       system to visualize the vessels. It usually involves computed tomographic scanning. The velocity of
       the blood flow can be estimated by duplex ultrasound. The client’s ankle-brachial index is
       determined, and then the client is requested to walk. The normal response is little or no drop in ankle
       systolic pressure after exercise.
       CN: Reduction of risk potential; CL: Apply

Question 20

20. A client is scheduled to have an arteriogram. During the arteriogram, the client reports having
    nausea, tingling, and dyspnea. The nurse’s immediate action should be to:
21. Administer epinephrine.
22. Inform the physician.
23. Administer oxygen.
24. Inform the client that the procedure is almost over.

Answer 20

20. 2. Clients may have an immediate or a delayed reaction to the radiopaque dye. The physician
       should be notified immediately because the symptoms suggest an allergic reaction. Treatment may
       involve administering oxygen and epinephrine. Explaining that the procedure is over does not address
       the current symptoms.
       CN: Physiological adaptation; CL: Synthesize

Question 21

21. A client with peripheral vascular disease has chronic, severe pretibial and ankle edema
    bilaterally. Because the client is on complete bed rest and circulation is compromised, one goal is to
    maintain tissue integrity. Which of the following interventions will help achieve this outcome?
22. Administering pain medication.
23. Encouraging fluids.
24. Turning the client every 1 to 2 hours.
25. Maintaining hygiene.

Answer 21

21. 3. The client is at greater risk for skin breakdown in the lower extremities related to the
       edema and to remaining in one position, which increases capillary pressure. Turning the client every
       1 to 2 hours promotes vasodilation and prevents vascular compression. Administering pain
       medication will not have an effect on skin integrity. Encouraging fluids is not a direct intervention for
       maintaining skin integrity, although being well hydrated is a goal for most clients. Maintaining hygiene
       does influence skin integrity but is secondary in this situation.
       CN: Physiological adaptation; CL: Synthesize

Question 22

22. A client who has been diagnosed with peripheral vascular disease (PVD) is beingdischarged. The client needs further instruction if she says she will:
23. Avoid heating pads.
24. Not cross the legs.
25. Wear leather shoes.
26. Use iodine on an injured site.

Answer 22

22. 4. The client should avoid using iodine or over-the-counter medications. Iodine is a highly
       toxic solution. An individual who has known PVD should be seen by a physician for treatment to
       avoid infection. The client with PVD should avoid heating pads and crossing the legs, and shouldwear leather shoes. A heating pad can cause injury, which, because of the decreased blood supply,
       can be difficult to heal. Crossing the legs can further impede blood flow. Leather shoes provide better
       protection.
       CN: Health promotion and maintenance; CL: Evaluate

Question 23

23. A client with peripheral vascular disease has bypass surgery. The primary goal of the plan of
care after surgery is to:
1. Maintain circulation.
2. Prevent infection.
3. Relieve pain.
4. Provide education.

Answer 23

23. 1. Maintaining circulation in the affected extremity after surgery is the focus of care. The graft
       can become occluded, and the client must be assessed frequently to determine whether the graft is
       patent. Preventing infection and relieving pain are important but are secondary to maintaining graft
       patency. Education should have taken place in the preoperative phase and then continued during the
       recovery phase.
       CN: Physiological adaptation; CL: Synthesize

Question 24

24. The nurse is instructing a client who is at risk for peripheral vascular disease how to use
    knee-length elastic stockings (support hose). The teaching plan should include which of the
    following? Select all that apply.
25. Apply the elastic stockings in the morning.
26. Remove the stockings if swelling occurs.
27. Apply the stockings while in bed.
28. Once the stockings have been pulled over the calf, roll the remaining stocking down to make a
    cuff.
29. Keep the stockings in place for 48 hours and reapply using a clean pair of stockings.

Answer 24

24. 1, 3. Elastic stockings (support hose) are used to promote circulation by preventing pooling of
    blood in the feet and legs. The stockings should be applied in the morning before the client gets out of
    bed. The stockings should be applied smoothly to avoid wrinkles, but the top should not be rolled
    down to avoid constriction of circulation. The stockings should be removed every 8 hours and the
    client should elevate the legs for 15 minutes and reapply the stockings. Clean stockings should be
    applied daily or as needed.
    CN: Health promotion and maintenance; CL: Create

Question 25

25. A client is scheduled to undergo right axillary-to-axillary artery bypass surgery. Which of the
    following interventions is most important for the nurse to implement in the preoperative period?
26. Assess the temperature in the affected arm.
27. Monitor the radial pulse in the affected arm.
28. Protect the extremity from cold.
29. Avoid using the arm for a venipuncture

Answer 25

25. 4. If surgery is scheduled, the nurse should avoid venipunctures in the affected extremity. The
       goal should be to prevent unnecessary trauma and possible infection in the affected arm. Disruptions
       in skin integrity and even minor skin irritations can cause the surgery to be canceled. The nurse can
       continue to monitor the temperature and radial pulse in the affected arm; however, doing so is not the
       priority. Keeping the client warm is important but is not the priority at this time.
       CN: Reduction of risk potential; CL: Analyze

Question 26

26. One goal in caring for a client with arterial occlusive disease is to promote vasodilation in
    the affected extremity. To achieve this goal, the nurse should encourage the client to:
27. Avoid eating low-fat foods.
28. Elevate the legs above the heart.
29. Stop smoking.
30. Begin a jogging program.

Answer 26

26. 3. Nicotine causes vasospasm and impedes blood flow. Stopping smoking is the most
       significant lifestyle change the client can make. The client should eat low-fat foods as part of a
       balanced diet. The legs should not be elevated above the heart because this will impede arterial flow.
       The legs should be in a slightly dependent position. Jogging is not necessary and probably is not
       possible for many clients with arterial occlusive disease. A rehabilitation program that includes daily
       walking is suggested.
       CN: Health promotion and maintenance; CL: Synthesize

Question 27

27. The client has aching, weakness, and a cramping sensation in both of the lower extremities
    while walking. To promote health and maintain the client’s level of activity, the nurse should suggest
    that the client try:
28. Crosscountry skiing.
29. Jogging.
30. Golfing.
31. Riding a stationary bike.

Answer 27

27. 4. In this case, the exercise prescription needs to be individualized because walking causes
       discomfort. To maintain the level of activity and decrease venous congestion, riding a stationary bike
       is another appropriate exercise behavior. Use of a stationary bike provides a non-weight-bearing
       exercise modality, which allows a longer duration of activity. Jogging and crosscountry skiing are
       weight-bearing activities. In addition, crosscountry skiing involves a cold environment, and
       maintaining warmth is essential in promoting arterial blood flow and preventing vasoconstriction.
       Golfing is a good activity, but it is not typically considered an exercise that causes aerobic changes in
       the body.
       CN: Health promotion and maintenance; CL: Synthesize

Question 28

28. The client with peripheral vascular disease has been prescribed diltiazem (Cardizem). The
    nurse should determine the effectiveness of this medication by assessing the client for:
29. Relief of anxiety.2. Sedation.
30. Vasoconstriction.
31. Vasodilation.

Answer 28

28. 4. Diltiazem is a calcium channel blocker that blocks the influx of calcium into the cell. In this
       situation, the primary use of diltiazem is to promote vasodilation and prevent spasms of the arteries.As a result of the vasodilation, blood, oxygen, and nutrients can reach the muscle and tissues.
       Diltiazem is not an antianxiety agent and does not promote sedation. It also does not cause
       vasoconstriction, which would be contraindicated for the client with peripheral vascular disease.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 29

29. A client is receiving pentoxifylline (Trental) for intermittent claudication. The nurse should
    determine the effectiveness of the drug by asking if the client:
30. Has improved circulation in the legs.
31. Can wiggle the toes.
32. Is urinating more frequently.
33. Is less dizzy

Answer 29

29. 1. Although pentoxifylline’s (Trental) precise mechanism of action is unknown, its therapeutic
       effect is to increase blood flow, and the client should have improved circulation in the legs. The
       client does not have nerve impairment and should be able to wiggle the toes. Urination is not
       improved by taking pentoxifylline. Dizziness is a side effect of the drug, not an intended outcome.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 30

30. A client with peripheral vascular disease, coronary artery disease and chronic obstructive
    pulmonary disease takes theophylline 200 mg twice daily every day, and digoxin 0.5 mg once a day.
    The physician now prescribes pentoxifylline. To prevent problematic adverse effects, the nurse
    should monitor the client’s:
31. Digoxin level.
32. Partial thromboplastin time (PTT).
33. Serum cholesterol level.
34. Theophylline level.

Answer 30

30. 4. Pentoxifylline can potentiate the effects of theophylline and increase the risk of theophylline
       toxicity. Therefore, the nurse should monitor the client’s theophylline level. Pentoxifylline does not
       interact with digoxin. Pentoxifylline can interact with heparin, and the client’s PTT would need to be
       monitored closely if the client were taking heparin. It does not affect cholesterol levels.
       CN: Pharmacological and parenteral therapies; CL: Analyze

Question 31

31. A client with a history of coronary artery disease (CAD) has been diagnosed with peripheral
    vascular disease. The physician started the client on pentoxifylline (Trental) once daily.
    Approximately 1 hour after receiving the initial dose of pentoxifylline, the client reports having chest
    pain. The nurse should first
32. Initiate the rapid response team.
33. Contact the physician.
34. Encourage the client to relax.
35. Document the episode in the chart.

Answer 31

31. 2. Angina is an adverse reaction to pentoxifylline, which should be used cautiously in clients
       with CAD. The nurse should report the client’s symptoms to the physician, who may prescribe
       nitroglycerin and possibly discontinue the pentoxifylline. The client should rest until the chest pain
       subsides, and documentation is essential when a client experiences an adverse reaction with
       medications that have been prescribed; however, the nurse’s top priority is to call the physician,
       report the problem, and obtain a prescription for nitroglycerin. The client’s reports of symptoms
       should never be dismissed.
       CN: Physiological adaptation; CL: Synthesize

Question 32

32. A client with peripheral vascular disease is recovering from an aortofemoral-popliteal
    bypass graft. When developing a postoperative education plan, which question by the nurse will
    provide the most helpful information?
33. “How did you manage your health before admission?”
34. “How far could you walk without pain before surgery?”
35. “What is your home environment like?”
36. “Do you have problems with urine retention?”

Answer 32

32. 1. Assessing the individual’s health behavior before surgery will help the nurse and client
       develop strategies to manage the postoperative course. Asking open-ended questions will elicit the
       most helpful information. The client’s ability to walk after surgery will be improved after surgery.
       The nurse can ask direct questions after obtaining general information.
       CN: Health promotion and maintenance; CL: Create

Question 33

33. The client with peripheral vascular disease and a history of hypertension is to be discharged
    on a low-fat, low-cholesterol, low-sodium diet. Which should be the nurse’s first step in planning the
    dietary instructions?
34. Determine the client’s knowledge level about cholesterol.
35. Ask the client to name foods high in fat, cholesterol, and salt.
36. Explain the importance of complying with the diet.
37. Assess the family’s food preferences.

Answer 33

33. 4. Before beginning dietary interventions, the nurse must assess the client’s pattern of food
       intake, life style, food preferences, and ethnic, cultural, and financial influences.
       CN: Basic care and comfort; CL: Synthesize

Question 34

The Client with Peripheral Vascular Disease
Having an Amputation
34. While the nurse is providing preoperative teaching for a client with peripheral vascular
disease who is to have a below-the-knee amputation, the client says, “I hate the idea of being an
invalid after they cut off my leg.” The nurse’s most therapeutic response should be:
1. “You’ll still have one good leg to use.”
2. “Tell me more about how you’re feeling.”
3. “Let’s finish the preoperative teaching.”
4. “You’re fortunate to have a wife who can take care of you.”

Answer 34

The Client with Peripheral Vascular Disease Having an
Amputation
34. 2. Encouraging the client who is undergoing amputation to verbalize feelings is the most
therapeutic nursing intervention. By eliciting concerns, the nurse may be able to provide information
to help the client cope. The nurse should avoid value-laden responses, such as “You’ll still have one
good leg,” that may make the client feel guilty or hostile and block further communication. The nurse
should not ignore the client’s expressed concerns, nor should the nurse reinforce the client’s concern
about invalidism and dependency or assume that his wife is willing to care for him.
CN: Psychosocial integrity; CL: Synthesize

Question 35

35. The client asks the nurse, “Why can’t the doctor tell me exactly how much of my leg they’re
    going to take off? Don’t you think I should know that?” The nurse responds, knowing that the final
    decision on the level of the amputation will depend primarily on:
36. The need to remove as much of the leg as possible.
37. The adequacy of the blood supply to the tissues.
38. The ease with which a prosthesis can be fitted.
39. The client’s ability to walk with a prosthesis.

Answer 35

35. 2. The level of amputation commonly cannot be accurately determined until surgery, when the
       surgeon can directly assess the adequacy of the circulation of the residual limb. A longer residual
       limb facilitates prosthesis fitting and will make it easier for the client to walk. However, although
       these aspects will be considered in the final decision, they are not the primary factors influencing the
       decision.
       CN: Physiological adaptation; CL: Synthesize

Question 36

36. A client has undergone an amputation of three toes and a femoral-popliteal bypass. The nurse
    should teach the client that after surgery which of the following leg positions is contraindicated while
    sitting in a chair?
37. Crossing the legs.
38. Elevating the legs.
39. Flexing the ankles.
40. Extending the knees.

Answer 36

36. 1. Leg crossing is contraindicated because it causes adduction of the hips and decreases the
       flow of blood into the lower extremities. This may result in increased pressure in the graft in the
       affected leg. Elevating the legs, flexing the ankles, and extending the knees are not necessarily
       contraindicated.
       CN: Reduction of risk potential; CL: Synthesize

Question 37

37. The nurse is monitoring a client after an above-the-knee amputation and notes that blood has
    saturated through the distal part of the dressing. The nurse should immediately:
38. Apply a tourniquet.
39. Assess vital signs.
40. Call the physician.
41. Elevate the surgical extremity with a large pillow.

Answer 37

37. 2. The client should be evaluated for hemodynamic stability and extent of bleeding prior to
       calling the physician. Direct pressure can be used prior to applying a tourniquet if there is significant
       bleeding. To avoid flexion contractures, which can delay rehabilitation, elevation of the surgical limb
       is contraindicated.
       CN: Reduction of risk potential; CL: Synthesize

Question 38

38. The client has had a below-the-knee amputation secondary to arterial occlusive disease. The
    nurse is instructing the client in residual limb care. Which of the following statements by the client
    indicates that the client understands how to implement the plan of care?
39. “I should inspect the incision carefully when I change the dressing every other day.”
40. “I should wash the incision, dry it, and apply moisturizing lotion daily.”
41. “I should rewrap the stump as often as needed.”
42. “I should elevate the stump on pillows to decrease swelling.”

Answer 38

38. 3. The purpose of wrapping the residual limb is to shape the residual limb to accept a
       prosthesis and bear weight. The compression bandaging should be worn at all times for many weeks
       after surgery and should be reapplied as needed to keep it free of wrinkles and snug. The dressing
       should be changed daily to allow for inspection of the stump incision. No lotions should be applied to
       the stump unless specifically prescribed by the physician. The stump should not be elevated on
       pillows because this will contribute to the formation of flexion contractures. Contractures will
       prevent the client from wearing a prosthesis and ambulating.
       CN: Physiological adaptation; CL: Evaluate

Question 39

The Client with Buerger’s Disease

39. Which of the following clients is at greatest risk for Buerger’s disease?
40. A 29-year-old male with a 14-year history of cigarette smoking.
41. A 38-year-old female who is taking birth control pills.
42. A 54-year-old female with adult-onset diabetes.
43. A 65-year-old male with atherosclerosis.

Answer 39

The Client with Buerger’s Disease
39. 1. Thromboangiitis obliterans (Buerger’s disease) is a nonatherosclerotic, inflammatory
vasoocclusive disorder. The disorder occurs predominantly in younger men less than 40 years of age
and there is a very strong relationship with tobacco use. Diagnosis is based on age of onset, history of
tobacco use, symptoms, and exclusion of diabetes mellitus.
CN: Reduction of risk potential; CL: Analyze

Question 40

40. The primary goal for the client with Buerger’s disease is to prevent:
41. Embolus formation.
42. Fat embolus formation.
43. Thrombus formation.
44. Thrombophlebitis.

Answer 40

40. 3. Because of the inflammation, a common complication of Buerger’s disease is thrombus
       formation and potential occlusion of the vessel. Inflammation of the immediate and small arteries and
       veins is involved in the disease process. Embolus is a potential risk if a thrombus has developed. Fat
       embolus is associated with fractures of the bones. Thrombophlebitis occurs after thrombus formation.
       CN: Health promotion and maintenance; CL: Synthesize

Question 41

41. A client with Buerger’s disease smokes two packs of cigarettes a day. When helping a client
    change smoking behavior, it is important to know the client’s:
42. Ability to attend support groups.
43. Goals for the treatment.
44. Perception of the negative behavior.
45. Motivation.

Answer 41

41. 3. When helping a client change detrimental health behavior, it is critical to learn how the
       client perceives the situation or problem. The client is more likely to change detrimental health
       behaviors if he realizes that there is a problem and that these behaviors lead to the problem. While
       understanding the client’s ability to attend group meetings, his goals for treatment, and his motivation
       may help facilitate change, the nurse should first understand the client’s perception of the problem andthen determine what strategies might work from his perspective.
       CN: Health promotion and maintenance; CL: Analyze

Question 42

42. A client with Buerger’s disease has established a goal to stop smoking. Which medication
    would be the most helpful in attaining this goal?
43. Bupropion.
44. Nicotine.
45. Nitroglycerin.
46. Ibuprofen.

Answer 42

42. 1. Bupropion is used to promote smoking cessation. All types of nicotine should be avoided to
       prevent vasoconstriction. Nitroglycerin, used for angina, and ibuprofen, an anti-inflammatory
       medication, have no role in smoking cessation.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 43

43. The nurse is assessing a client with Buerger’s disease. The nurse should determine if the
    client is experiencing:
44. Thickening of the intima and media of the artery.
45. Inflammation and fibrosis of arteries, veins, and nerves.
46. Vasospasm lasting several minutes.
47. Pain, pallor, and pulselessness.

Answer 43

43. 2. Buerger’s disease is characterized by inflammation and fibrosis of arteries, veins, and
       nerves. White blood cells infiltrate the area and become fibrotic, which results in occlusion of the
       vessels. Signs and symptoms include slowly developing claudication, cyanosis, coldness, and pain at
       rest. Thickening of the intima and media of the artery is characteristic of atherosclerosis. Vasospasm
       lasting several minutes is characteristic of Raynaud’s disease. Pain, pallor, and pulselessness are
       symptoms of acute occlusion of an artery by an embolus or other cause (eg, compartment syndrome).
       CN: Health promotion and maintenance; CL: Analyze

Question 44

The Client with Vasospastic Disorder
44. When instructing a client who has been newly diagnosed with vasospastic disorder
(Raynaud’s phenomenon) about management of care, the nurse should discuss which of the following
topics?
1. Scheduling a sympathectomy procedure for the next visit.
2. Using a beta blocker medication.
3. Follow-up monitoring for development of connective tissue disease.
4. Benefit of an angioplasty to the affected extremities.

Answer 44

The Client with Vasospastic Disorder
44. 3. Clients with Raynaud’s phenomenon should receive routine follow-up to monitor symptoms
and to assess for the development of connective tissue or autoimmune diseases associated with
Raynaud’s. Beta blockers are not considered first-line drug therapy. A sympathectomy is considered
only in advanced cases. There is no benefit to an angioplasty, which is used for atherosclerotic
vascular disease.
CN: Health promotion and maintenance; CL: Create

Question 45

45. A client has been diagnosed with vasospastic disorder (Raynaud’s phenomenon) on the tip of
    the nose and fingertips. The physician has prescribed reserpine (Serpasil) to determine if the client
    will obtain relief. The client often works outside in cold weather and also smokes two packs of
    cigarettes per day. Which of the following should be included in the discharge plan for this client?
    Select all that apply.
46. Stopping smoking.
47. Wearing a face covering and gloves in the winter.
48. Placing fingertips in cool water to rewarm them.
49. Finding employment that can be done in a warm environment.
50. Reporting signs of orthostatic hypotension.

Answer 45

45. 1, 2, 5. Vasospastic disorder (Raynaud’s disease) is a form of intermittent arteriolar
    vasoconstriction that results in coldness, pain, and pallor of the fingertips, toes, or tip of the nose, and
    a rebound circulation with redness and pain. The nurse should instruct the client to stop smoking
    because nicotine is a vasoconstrictor. An adverse effect of reserpine is orthostatic hypotension. The
    client should report dizziness and low blood pressure as it may be necessary to consider stopping the
    drug. The client should prevent vasoconstriction by covering affected parts when in cold
    environments. The nurse can teach the client to rewarm exposed extremities by using warm water or
    placing them next to the body, such as under the axilla. It is not realistic to ask this client to change
    jobs at this time.
    CN: Health promotion and maintenance; CL: Create

Question 46

46. A nurse assesses a 40-year-old female client with vasospastic disorder (Raynaud’s
    phenomenon) involving her right hand. The nurse notes the information in the progress notes, as
    shown below. From these findings, the nurse should develop a plan with the client to first manage:

06/10/08 3pm The client has a palpable but faint right radial pulse. Capillary refill on all five digits <8s. No observable swelling. The client is reporting numbness in the tips of all five digits. The skin is warm, dry, and red.
G. Fuentes, RN

1. Acute pain.
2. Numbness.
3. Lack of circulation.
4. Potential for skin breakdown.

Answer 46

46. 2. The client has numbness in the fingertips, and the nurse should first help the client regain
       sensory perception and discuss strategies for prevention of injury. The client does not have acute
       pain. The client does have adequate circulation and is not at risk for skin breakdown at this time.
       CN: Physiological adaptation; CL: Analyze

Question 47

47. Which of the following clients is at greatest risk for vasospastic disorder (Raynaud’s
    phenomenon) ?
48. Young women.
49. Old women.3. Old men.
50. Young men.

Answer 47

47. 1. Vasospastic disorder (Raynaud’s disease) is more common in young women and is
       associated with collagen diseases such as rheumatoid arthritis and lupus.
       CN: Physiological adaptation; CL: Analyze

Question 48

48. The client with vasospastic disorder (Raynaud’s phenomenon) has coldness and numbness in
    the fingers. The nurse assesses the client for effects of vasoconstriction. Which of the following is an
    early sign of vasoconstriction?
49. Cyanosis.
50. Gangrene.
51. Pallor.
52. Rubor.

Answer 48

48. 3. Initially, the vasoconstriction effect produces pallor or a whitish coloring, followed by
       cyanosis (bluish) and finally rubor (red). Gangrene is the end result of complete arterial occlusion;the skin is blackened and without a blood supply.
       CN: Reduction of risk potential; CL: Analyze

Question 49

49. During an initial assessment of a client diagnosed with vasospastic disorder (Raynaud’s
    phenomenon), the nurse notes a sudden color change from pink to white in the fingers. The nurse
    should first assess:
50. Appearance of cyanosis.
51. Radial pulse.
52. SpO 2 of the affected fingers.
53. Blood pressure.

Answer 49

49. 2. Decreased perfusion from vasospasm induces color changes in the extremity. The degree of
       decreased perfusion should be assessed by taking the radial pulse. Color changes progressively to
       blue with cyanosis and then red when reperfusion occurs. The SpO 2 requires adequate perfusion for
       accuracy. A blood pressure will cause further constriction and reduction of perfusion in the extremity.
       CN: Physiological adaptation; CL: Analyze

Question 50

50. The nurse should instruct a client who has been diagnosed with vasospastic disorder
    (Raynaud’s phenomenon) to:
51. Immerse the hands in cold water during an episode.
52. Wear light garments when the temperature gets below 50°F (10°C).
53. Wear gloves when handling ice or frozen foods.
54. Live in a cold climate.

Answer 50

50. 3. Extreme changes in temperature can precipitate a vasospastic episode and should be
       avoided by clients with vasospastic disorder (Raynaud’s disease). The client should be encouraged to
       wear gloves when handling frozen foods or ice. The client should immerse the involved extremity in
       warm water during an episode to promote vasodilation and relaxation of the small arteries that are in
       spasm. The client can help prevent vasospasm brought on by temperature changes by wearing warm
       clothes. Living in a cold climate will exacerbate the symptoms.
       CN: Health promotion and maintenance; CL: Synthesize

Question 51

51. In order to prevent recurrent vasospastic episodes with Raynaud’s phenomenon, the nurse
    should instruct the client to:
52. Keep the hands and feet elevated as much as possible.
53. Use a vibrating massage device on the hands.
54. Wear gloves when obtaining food from the refrigerator.
55. Increase coffee intake to two cups per day.

Answer 51

51. 3. Loose warm clothing should be worn to protect from the cold. Wearing gloves when
       handling cold objects will help prevent vasospasms. Vibrating equipment and typing contribute to
       vasospasm. Tobacco and caffeine should be avoided. Elevation will decrease arterial perfusion
       during vasospasms.
       CN: Health promotion and maintenance; CL: Synthesize

Question 52

52. A client with Raynaud's phenomenon is prescribed diltiazem (Cardizem). An expected
outcome is:
1. Decreased heart rate.
2. Conversion to normal sinus rhythm.
3. Reduced episodes of finger numbness.
4. Increased SpO 2 .

Answer 52

52. 3. Calcium channel blockers are first-line drug therapy for the treatment of vasospasms with
       Raynaud’s phenomenon when other therapies are ineffective. Cardizem relaxes smooth muscles and
       improves peripheral perfusion, therefore reducing finger numbness. Cardizem decreases heart rate
       and is used to treat atrial fibrillation, but these are not associated with Raynaud’s. When vasospasms
       are prevented, an accurate SpO 2 can be measured in the affected extremity; however, SpO 2 is a
       measurement of systemic oxygenation not influenced by Cardizem.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 53

53. When giving discharge instructions to the client with vasospastic disorder (Raynaud’s
    phenomenon), the nurse should explain that the expected outcome of taking a beta-adrenergic blocking
    medication is to control the symptoms by:
54. Decreasing the influence of the sympathetic nervous system on the tissues in the hands and feet.
55. Decreasing the pain by producing analgesia.
56. Increasing the blood supply to the affected area.
57. Increasing monoamine oxidase.

Answer 53

53. 1. Beta-adrenergic medications block the beta-adrenergic receptors. Therefore, the expected
       outcome of the medication is to decrease the influence of the sympathetic nervous system on the blood
       vessels in the hands. Beta-adrenergic blockers have no analgesic effects. Increasing blood supply to
       the affected area is an indirect effect of beta-adrenergic blockers. They do not increase monoamine
       oxidase, which does not play a role in Raynaud’s disease.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 54

54. A client with vasospastic disorder (Raynaud’s phenomenon) is considering having asympathectomy. This nurse should tell the client that the surgery is performed:
55. In the early stages of the disease to prevent further circulatory disturbances.
56. When the disease is controlled by medication.
57. When the client is unable to control stress-related vasospasm.
58. When all other treatment alternatives have failed

Answer 54

54. 4. Sympathectomy is scheduled only after other treatment alternatives have been explored and
       have failed. Medication and stress management are beneficial strategies to prevent advancement of
       the disease process. If the disease is controlled by medication, there is no reason for surgery.
       CN: Physiological adaptation; CL: Apply

Question 55

he Client with Thrombophlebitis and Embolus Formation
A client is being treated for deep vein thrombosis (DVT) in the left femoral artery. The physician has prescribed 60 mg of enoxaparin (Lovenox) subcutaneously. Before administering the drug, the nurse
checks the client’s laboratory results, noted below.

PROTHROMBIN TIME 12.5 seconds
INR 2.0 s
PLATELET COUNT 50,000 /uL

Based on these results, the nurse should:

1. Assess the client for bleeding.
2. Administer the medication.
3. Inform the physician.
4. Withhold the dose of Lovenox.

Answer 55

The Client with Thrombophlebitis and Embolus Formation
55. 4. Based on the laboratory findings, prothrombin time and INR are at acceptable
anticoagulation levels for the treatment of DVT. However, the platelets are below the acceptablelevel. Clients taking enoxaparin are at risk for thrombocytopenia. Because of the low platelet level,
the nurse should withhold the enoxaparin, assess the client for bleeding, and then contact the
physician.
CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 56

56. A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest
    discomfort. What should the nurse do first?
57. Elevate the head of the bed 30 to 45 degrees.
58. Encourage the client to cough and deep breathe.
59. Auscultate the lungs to detect abnormal breath sounds.
60. Contact the physician.

Answer 56

56. 1. Elevating the head of the bed facilitates breathing because the lungs are able to expand as
       the diaphragm descends. Coughing and deep breathing do not alleviate the symptoms of a pulmonary
       embolus, nor does lung auscultation. The physician must be kept informed of changes in a client’s
       status, but the priority in this case is alleviating the symptoms.
       CN: Reduction of risk potential; CL: Synthesize

Question 57

57. The nurse is caring for a client with acute arterial occlusion of the left lower extremity. To
    prevent further tissue damage, it is important for the nurse to observe for which of the following?
58. Blood pressure and heart rate changes.
59. Gradual or acute loss of sensory and motor function.
60. Metabolic acidosis.
61. Swelling in the left lower extremity

Answer 57

57. 2. Acute arterial occlusion is a sudden interruption of blood flow. The interruption can be the
       result of complete or partial obstruction. Acute pain, loss of sensory and motor function, and a pale,
       mottled, numb extremity are the most dramatic and observable changes that indicate a life-threatening
       interruption of tissue perfusion. Blood pressure and heart rate changes may be associated with the
       acute pain episode. Metabolic acidosis is a complication of irreversible ischemia. Swelling may
       result but may also indicate venous stasis or arterial insufficiency.
       CN: Physiological adaptation; CL: Analyze

Question 58

58. A client with venous thrombus reports having pain in the legs. The nurse should first:
59. Elevate the foot of the bed.
60. Elevate the legs by using a pillow under the knees.
61. Encourage adequate fluid intake.
62. Massage the lower legs.

Answer 58

58. 1. Venous stasis can increase pain. Therefore, proper positioning in bed with the foot of the
       bed elevated or when sitting up in a chair can help promote venous drainage, reduce swelling, and
       reduce the amount of pain the client might experience. Placing a pillow under the knees causes flexion
       of the joint, resulting in a dependent position of the lower leg and causing a decrease in blood flow.
       Fluids are encouraged to maintain normal fluid and electrolyte balance but do little to relieve pain.
       Therapeutic massage to the legs is discouraged because of the danger of breaking up the clot.
       CN: Basic care and comfort; CL: Synthesize

Question 59

59. A 45-year-old client had a complete abdominal hysterectomy with bilateral salpingo-
    oophorectomy 2 days ago. The client’s abdominal dressing is dry and intact. The client is taking
    liquids and voiding a sufficient quantity of straw-colored urine. While sitting up in the chair, the
    client has severe pain and numbness in her left leg. The nurse should first:1. Administer pain medication.
60. Assess edema in the left leg.
61. Assess color and temperature of the left leg.
62. Encourage the client to change her position.

Answer 59

59. 3. The client is likely suffering from an embolus as a result of abdominal surgery. The nurse
       should inspect the left leg for color and temperature changes associated with tissue perfusion.
       Administering pain medication without gathering more information about the pain can mask important
       signs and symptoms. Although assessing for edema is important, it is not critical to this situation.
       Encouraging the client to change her position does not adequately address the need for gathering more
       data.
       CN: Reduction of risk potential; CL: Synthesize

Question 60

60. A client who is being discharged after a hospitalization for thrombophlebitis will be riding
    home in a car. During the 2-hour ride, the nurse should advise the client to:
61. Perform arm circles while riding in the car.
62. Perform ankle pumps and foot range-of-motion exercises.
63. Elevate the legs while riding in the car.
64. Take an ambulance home.

Answer 60

60. 2. Performing active ankle and foot range-of-motion exercises periodically during the ride
       home will promote muscular contraction and provide support to the venous system. It is the muscular
       action that facilitates return of the blood from the lower extremities, especially when in the dependent
       position. Arm circle exercises will not promote circulation in the leg. It is not necessary for the client
       to elevate the legs as long as the client does not occlude blood flow to the legs and does the leg
       exercises. It is not necessary to take an ambulance because the client is able to sit in the car safely.
       CN: Reduction of risk potential; CL: Synthesize

Question 61

61. A client is admitted with an acute onset of shortness of breath. A diagnosis of pulmonary
    embolism is made. One common cause of pulmonary embolism is:
62. Arteriosclerosis.
63. Aneurysm formation.
64. Deep vein thrombosis (DVT).
65. Varicose veins.

Answer 61

61. 3. DVT is commonly associated with venous stasis in the legs when there is a lack of the
       skeletal muscle pump that enhances venous return to the heart. When a client is confined to bed rest,
       venous compression occurs because of the position of the lower extremities. This increased pressure
       causes damage to the intima lining of the veins and causes platelets to adhere to the damaged site.DVT increases the risk that a displaced plaque will become a pulmonary embolus. Arteriosclerosis is
       hardening of the arteries; aneurysm is the abnormal dilation of a vessel; and varicose veins are
       swollen, tortuous veins. These are not generally considered causes of pulmonary embolism.
       CN: Physiological adaptation; CL: Apply

Question 62

62. A client with a cerebral embolus is receiving streptokinase. The nurse should evaluate the
    client for which of the following expected outcomes of this drug therapy?
63. Improved cerebral perfusion.
64. Decreased vascular permeability.
65. Dissolved emboli.
66. Prevention of cerebral hemorrhage.

Answer 62

62. 3. Thrombolytic agents such as streptokinase are used for clients with a history of thrombus
       formation, cerebrovascular accidents, and chronic atrial fibrillation. The thrombolytic agents act by
       dissolving emboli. Thrombolytic agents do not directly improve perfusion or increase vascular
       permeability, nor do they prevent cerebral hemorrhage.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 63

63. A client who weighs 187 lb (85 kg) has a prescription to receive enoxaparin (Lovenox) 1 mg/kg. This
    drug is available in a concentration of 30 mg/0.3 mL. What dose would the nurse administer in
    milliliters?
    _________________ mL.

Answer 63

63. 0.85 mL
    The physician’s prescription is for the client to receive enoxaparin (Lovenox) 1 mg/kg. Therefore,
    the client is to receive 85 mg. The desired dose in milliliters then can be calculated by using the
    formula of desired dose (D) divided by dose or strength of dose on hand (H) times volume (V).
    CN: Pharmacological and parenteral therapies; CL: Apply

Question 64

64. A client is on complete bed rest. The nurse should assess the client for risk for developing
which of the following complications?
1. Air embolus.
2. Fat embolus.
3. Stress fractures.
4. Thrombophlebitis.

Answer 64

64. 4. Thrombophlebitis is an inflammation of a vein. The underlying etiology involves stasis of
       blood, increased blood coagulability, and vessel wall injury. The symptoms of thrombophlebitis are
       pain, swelling, and deep muscle tenderness. Air embolus is a result of air entering the vascular
       system. Fat embolus is associated with the presence of intracellular fat globules in the lung
       parenchyma and peripheral circulation after long-bone fractures. Stress fractures are associated with
       the musculoskeletal system.
       CN: Health promotion and maintenance; CL: Analyze

Question 65

65. Knee-high sequential compression devices have been prescribed for a newly admitted client.
    The client reports new pain localized in the right calf area that is noted to be slightly reddened and
    warm to touch upon initial assessment. The nurse should first:
66. Offer analgesics as prescribed and apply the compression devices.
67. Leave the compression devices off and contact the physician to report the assessment findings.
68. Massage the area of discomfort before applying the compression devices.
69. Leave the compression devices off and report assessment findings to the oncoming shif

Answer 65

65. 2. Localized pain, tenderness, redness, and warmth may be symptoms of deep vein thrombosis
       (DVT), information the nurse should report to the physician; the compression devices should not be
       applied until further evaluation is completed as intermittent compression may dislodge a thrombus.
       Massaging the area may dislodge a thrombus and is not recommended. The nurse may offer PRN
       analgesics if the client requires pain management, but the compression devices should not be applied
       until further evaluation is completed. Diagnosis and treatment of DVT should be discussed with the
       physician as soon as possible; the nurse should not wait until the next shift to report findings as a
       DVT can become life threatening if a thrombus travels to the lung and becomes a pulmonary embolus.
       CN: Reduction of risk potential; CL: Synthesize

Question 66

66. A client is receiving an IV infusion of 5% dextrose in water (D 5 W). The skin around the IV
    insertion site is red, warm to touch, and painful. The nurse should first:1. Administer acetaminophen (Tylenol).
67. Change the D 5 W to normal saline.
68. Discontinue the IV.
69. Place a warm compress on the area.

Answer 66

66. 3. The first action should be to discontinue the IV. The nurse should restart the IV elsewhere
       and then apply a warm compress to the affected area. The nurse should administer acetaminophen or
       an anti-inflammatory agent only if prescribed by the physician. The type of infusion cannot be changed
       without a physician’s prescription, and such a change would not help in this case.
       CN: Reduction of risk potential; CL: Synthesize

Question 67

67. The nurse is planning care for a client on complete bed rest. The plan of care should include
    all except which of the following:
68. Turning every 2 hours.
69. Passive and active range-of-motion exercises.
70. Use of thromboembolic disease (TED) support hose.
71. Maintaining the client in the supine position.

Answer 67

67. 4. Three factors contribute to the formation of venous thrombus and thrombophlebitis: damage
       to the inner lining of the vein (prolonged pressure), hypercoagulability of the blood, and venous
       stasis. Bed rest and immobilization are associated with decreased blood flow and venous pooling in
       the lower extremities. Keeping the client in the supine position would not be appropriate. Turning the
       client every 1 to 2 hours, passive and active range-of-motion exercises, and use of TED hose help
       prevent venous stasis in the lower extremities.CN: Reduction of risk potential; CL: Create

Question 68

68. The client is admitted with left lower leg pain, a positive Homans’ sign, and a temperature of
69. 4°F (38°C). The nurse should assess the client further for signs of:
70. Aortic aneurysm.
71. Deep vein thrombosis (DVT) in the left leg.
72. IV drug abuse.
73. Intermittent claudication.

Answer 68

68. 2. The client demonstrates classic symptoms of DVT, and the nurse should continue to assess
       the client. Signs and symptoms of an aortic aneurysm include abdominal pain and a pulsating
       abdominal mass. Clients with drug abuse demonstrate confusion and decreased levels of
       consciousness. Claudication is an intermittent pain in the leg.
       CN: Psychosocial integrity; CL: Analyze

Question 69

69. A client is admitted with a diagnosis of thrombophlebitis and deep vein thrombosis of the
    right leg. A loading dose of heparin has been given in the emergency room, and IV heparin will be
    continued for the next several days. The nurse should develop a plan of care for this client that will
    involve:
70. Administering aspirin as prescribed.
71. Encouraging green leafy vegetables in the diet.
72. Monitoring the client’s prothrombin time (PT).
73. Monitoring the client’s activated partial thromboplastin time (aPTT) and International
    Normalized Ratio (INR).

Answer 69

69. 4. Heparin dosage is usually determined by the physician based on the client’s aPTT and INR
       laboratory values. Therefore, the nurse monitors these values to prevent complications. Administering
       aspirin when the client is on heparin is contraindicated. Green leafy vegetables are high in vitamin K
       and therefore are not recommended for clients receiving heparin. Monitoring of the client’s PT is
       done when the client is receiving warfarin sodium (Coumadin).
       CN: Pharmacological and parenteral therapies; CL: Create

Question 70

70. In order to prevent deep vein thrombosis (DVT) following abdominal surgery, the nurse
    should:
71. Restrict fluids.
72. Encourage deep breathing.
73. Assist the client to remain sedentary.
74. Use pneumatic compression stockings.

Answer 70

70. 4. The use of pneumatic compression stockings is an intervention used to prevent DVT. Other
       strategies include early ambulation, leg exercises if the client is confined to bed, adequate fluid
       intake, and administering anticoagulant medication as prescribed. Deep breathing would be
       encouraged postoperatively, but it does not prevent DVT.
       CN: Health promotion and maintenance; CL: Synthesize

Question 71

71. A client diagnosed with a deep vein thrombosis has heparin sodium infusing at 1,500 units/h. The
    concentration of heparin is 25,000 units/500 mL. If the infusion remains at the same rate for a full 12-
    hour shift, how many milliliters of fluid will infuse?
    __________________________-mL.

Answer 71

71. 360 mL

CN: Pharmacological and parenteral therapies; CL: Apply

Question 72

72. The nurse interviews a 22-year-old female client who is scheduled for abdominal surgery the
    following week. The client is obese and uses estrogen-based oral contraceptives. This client is at
    high risk for development of:
73. Atherosclerosis.
74. Diabetes.
75. Vasospastic disorder (Raynaud’s disease).
76. Thrombophlebitis

Answer 72

72. 4. The data suggest an increased risk of thrombophlebitis. The risk factors in this situation
       include abdominal surgery, obesity, and use of estrogen-based oral contraceptives. Risk factors for
       atherosclerosis include genetics, older age, and a high-cholesterol diet. Risk factors for diabetes
       include genetics and obesity. Risk factors for vasospastic disorders include cold climate, age (16 to
       40), and immunologic disorders.
       CN: Reduction of risk potential; CL: Analyze

Question 73

73. The nurse observes that an older female has small-to-moderate, distended, and tortuous veins
    running along the inner aspect of her lower legs. The nurse should:
74. Apply a half-leg pneumatic compression device.
75. Suggest the client contact her physician.
76. Assess the client for foot ulcers.
77. Encourage the client to avoid standing in one position for long periods of time.

Answer 73

73. 4. The client has varicose veins, which are evident by the tortuous, distended veins where
       blood has pooled. To prevent pooling of the blood, the client should not stand in one place for long
       periods of time. It is not necessary to use compression devices, but the client could wear support hose
       if she stands for long periods of time. The client can consider cosmetic surgery to remove the
       distended veins, but there is no indication that the client should contact the physician at this point in
       time. The nurse can inspect the client’s feet, but the client is not at risk for ulcers at this time.
       CN: Health promotion and maintenance; CL: Synthesize

Question 74

74. Which of the following clients is at risk for varicose veins?
75. A client who has had a cerebrovascular accident.
76. A client who has had anemia.
77. A client who has had thrombophlebitis.
78. A client who has had transient ischemic attacks

Answer 74

74. 3. Secondary varicosities can result from previous thrombophlebitis of the deep femoral
       veins, with subsequent valvular incompetence. Cerebrovascular accident, anemia, and transient
       ischemic attacks are not associated with an increased risk of varicose veins.
       CN: Health promotion and maintenance; CL: Analyze

Question 75

75. A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and
    thrombophlebitis. When reviewing a teaching plan with this client, the nurse determines that the client
    has understood the nurse’s instructions when the client states a willingness to:
76. Avoid exercise.
77. Lose weight.
78. Perform leg lifts every 4 hours.
79. Wear support hose, using rubber bands to hold the stockings up.

Answer 75

75. 2. The client is at risk for development of varicose veins. Therefore, prevention is key in the
       treatment plan. Maintaining ideal body weight is the goal. In order to achieve this, the client should
       consume a balanced diet and participate in a regular exercise program. Depending on the individual,
       leg lifts may or may not be an appropriate activity. Performing leg lifts provides muscular activity andshould be done more often than every 4 hours. Wearing support hose is helpful. However, the client
       should not use rubber bands to hold the stockings up.
       CN: Reduction of risk potential; CL: Evaluate

Question 76

76. Which instructions should the nurse include when developing a teaching plan for a client
    being discharged from the hospital on anticoagulant therapy after having deep vein thrombosis
    (DVT)? Select all that apply.
77. Checking urine for bright blood and a dark smoky color.
78. Walking daily as a good exercise.
79. Using garlic and ginger, which may decrease bleeding time.
80. Performing foot/leg exercises and walking around the airplane cabin when on long flights.
81. Preventing DVT because of risk of pulmonary emboli.
82. Avoiding surface bumps because the skin is prone to injury.

Answer 76

76. 1, 2, 4, 5, 6. Clients with resolving DVT being sent home on anticoagulant therapy need
    instructions about assessing and preventing bleeding episodes and preventing a recurrence of DVT.
    Blood in the urine (hematuria) is often one of the first symptoms of anticoagulant overdose. Fresh
    blood in the urine is red; however, blood in the urine may also be a dark smoky color. Daily
    ambulation is an excellent activity to keep the venous blood circulating and thus to prevent blood
    clots from forming in the lower extremities. Garlic and ginger increase the bleeding time and should
    not be used when a client is on anticoagulant therapy. Clients who have had previous DVTs should
    avoid activities that cause stagnation and pooling of venous blood. Prolonged sitting coupled with
    change of air pressure without foot or leg exercises or ambulation in the cabin are activities that
    prevent venous return. Instructing the client about prevention measures is important because clients
    with DVT are at high risk for pulmonary emboli (PE), which can be fatal. The client can be taught
    risk factors for DVT and PE. In addition, recommendations for prevention of these events also are
    standard protocol in practice and should be shared with the client for home care purposes. Older
    adults should be monitored closely for bleeding because the skin becomes thinner and the capillaries
    become more fragile with the aging process.
    CN: Health promotion and maintenance; CL: Create

Question 77

77. A client has an emergency embolectomy for an embolus in the femoral artery. After the client
    returns from the recovery room, in what order, from first to last, should the nurse provide care?
78. Administer pain medication.
79. Draw blood for laboratory studies.
80. Regulate the IV infusion.
81. Monitor the pulses.
82. Inspect the dressing.

Answer 77

77.
4. Monitor the pulses.
5. Inspect the dressing.
3. Regulate the IV infusion.
1. Administer pain medication.
2. Draw blood for laboratory studies.
The nurse should first monitor the popliteal and the pedal pulses in the affected extremity after
arterial embolectomy. Monitoring peripheral pulses below the site of occlusion checks the arterial
circulation in the involved extremity. The nurse should next inspect the dressing to be sure that the
client is not bleeding at the surgical site. The nurse should next regulate the IV infusion to prevent
fluid overload. Then the nurse should assess pain and administer pain medications as prescribed.
Last, the nurse can obtain blood for laboratory studies.
CN: Physiological adaptation; CL: Synthesize

Question 78

The Client with an Aneurysm
The nurse is developing a discharge teaching plan for a client who underwent a repair of abdominal
aortic aneurysm 4 days ago. The nurse reviews the client’s chart for information about the client’s
history. Key findings are noted in the chart below.

HISTORY AND PHYSICAL

1) Smokes four cigars a month
2) Vital signs blood pressure, ranges from 150/76 -170/98 mmHg’ heart rate 90-100 bpm; respirations 12-18 bpm; temperature 99.9 F (37.8 C)
3) +1 bilateral ankle edema

Based on the data and expected outcomes, which should the nurse emphasize in the teaching plan?

1. Food intake.
2. Fluid volume.
3. Skin integrity.
4. Tissue perfusion.

Answer 78

The Client with an Aneurysm78. 4. The underlying pathophysiology in this client is atherosclerosis. The findings from the
assessment indicate the risk factors of smoking and high blood pressure. Therefore, tissue perfusion is
a priority for health promoting education. The data do not support education that focuses on food or
fluid intake. Although edema is a potential problem and could contribute to poor skin integrity, the
edema will likely be resolved by the aneurysm repair.
CN: Physiological adaptation; CL: Synthesize

Question 79

A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records findings from the initial
assessment in the client’s chart, as shown below.
At 10:30 AM , the client has sharp midchest pain after having a bowel movement. What should the
nurse do first?
1. Assess the client’s vital signs.
2. Administer a bolus of lactated Ringer’s solution.
3. Assess the client’s neurologic status.
4. Contact the physician.

Answer 79

79. 1. The size of the thoracic aneurysm is rather large, so the nurse should anticipate rupture. A
       sudden incidence of pain may indicate leakage or rupture. The blood pressure and heart rate will
       provide useful information in assessing for hypovolemic shock. The nurse needs more data before
       initiating other interventions. After assessment of vital signs, neurologic status, and pain, the nurse
       can then contact the physician. Administering lactated Ringer’s solution would require a physician’s
       prescription.
       CN: Physiological adaptation; CL: Synthesize

Question 80

80. Nursing assessment of a 54-year-old client in the emergency department reveals severe back
    pain, Grey Turner’s sign, nausea, blood pressure of 90/40, heart rate 128 bpm, and respirations
    28/min. The nurse should first:
81. Assess the urine output.2. Place a large-bore IV
82. Position onto the left side.
83. Insert a nasogastric tube.

Answer 80

80. 2. The symptoms suggest an abdominal aortic aneurysm that is leaking or rupturing. An IV
       should be inserted for immediate volume replacement. With hypovolemia, the urine output will be
       diminished. Repositioning may potentiate the problem. A nasogastric tube may be considered with
       severe nausea and vomiting to decompress the stomach.
       CN: Physiological adaptation; CL: Synthesize

Question 81

81. A client had a repair of a thoracoabdominal aneurysm 2 days ago. Which of the following
    findings should the nurse consider unexpected and report to the physician immediately? The client
    has:
82. Abdominal pain at 5 on a scale of 0 to 10 for the last 2 days.
83. Heart rate of 100 bpm after ambulating 200 feet (0.06 km).
84. Urine output of 2,000 mL in 24 hours.
85. Weakness and numbness in the lower extremities.

Answer 81

81. 4. One of the complications of a thoracoabdominal aneurysm repair is spinal cord injury.
       Therefore, it is important for the nurse to assess for signs and symptoms of neurologic changes at and
       below the site where the aneurysm was repaired. The client is expected to have moderate pain
       following surgery. An elevated heart rate is expected after physical exertion. It is important to
       monitor urine output following aneurysm surgery, but a urine output of 2,000 mL in 24 hours is
       adequate following surgery.
       CN: Safety and infection control; CL: Synthesize

Question 82

82. A client is admitted to the emergency department with severe abdominal pain. A radiograph
    reveals a large abdominal aortic aneurysm. The primary goal at this time is to:
83. Maintain circulation.
84. Manage pain.
85. Prepare the client for emergency surgery.
86. Teach postoperative breathing exercises.

Answer 82

82. 3. The primary goal is to prepare the client for emergency surgery. The goal would be to
       prevent rupture of the aneurysm and potential death. Circulation is maintained, unless the aneurysm
       ruptures. When the client is prepared for surgery, the nurse should place the client in a recumbent
       position to promote circulation, teach the client about postoperative breathing exercises, and
       administer pain medication if prescribed.
       CN: Physiological adaptation; CL: Synthesize

Question 83

83. Before surgery for a known aortic aneurysm, the client’s pulse pressure begins to widen,
    suggesting increased aortic valvular insufficiency. If the branches of the aortic arch are involved, the
    nurse should assess the client for:
84. Loss of consciousness.
85. Anxiety.
86. Headache.
87. Disorientatio

Answer 83

83. 1. If the aortic arch is involved, there will be a decrease in the blood flow to the cerebrum.
       Therefore, loss of consciousness will be observed. A sudden loss of consciousness is a primary
       symptom of rupture and no blood flow to the brain. Anxiety is not a sign of aortic valvular
       insufficiency. The end result of decreased cerebral blood flow is loss of consciousness, not headache
       or disorientation.
       CN: Reduction of risk potential; CL: Analyze

Question 84

84. A client has sudden, severe pain in the back and chest, accompanied by shortness of breath.
    The client describes the pain as a “tearing” sensation. The physician suspects the client is
    experiencing a dissecting aortic aneurysm. The emergency supply cart is brought into the room
    because one complication of a dissecting aneurysm is:
85. Cardiac tamponade.
86. Stroke.
87. Pulmonary edema.
88. Myocardial infarction.

Answer 84

84. 1. Cardiac tamponade is a life-threatening complication of a dissecting thoracic aneurysm.
       The sudden, painful “tearing” sensation is typically associated with the sudden release of blood, and
       the client may experience cardiac arrest. Stroke, pulmonary edema, and myocardial infarction are not
       common complications of a dissecting aneurysm.CN: Physiological adaptation; CL: Apply

Question 85

85. Which of the following increases the risk of having a large abdominal aortic aneurysm
rupture?
1. Anemia.
2. Dehydration.
3. High blood pressure.
4. Hyperglycemia.

Answer 85

85. 3. In the preoperative phase, the goal is to prevent rupture. The client is placed in a semi-
       Fowler’s position and in a quiet environment. The systolic blood pressure is maintained at the lowest
       level the client can tolerate. Anemia, dehydration, and hyperglycemia do not put the client at risk for
       rupture.
       CN: Health promotion and maintenance; CL: Analyze

Question 86

86. The nurse is planning care for a client who has just returned to the medical-surgical unit
    following repair of an aortic aneurysm. The nurse first should assess the client for:
87. Decreased urinary output.
88. Electrolyte imbalance.
89. Anxiety.4. Wound infection.

Answer 86

86. 1. Following surgical repair of an aortic aneurysm, there is a potential for an alteration in
       renal perfusion, manifested by decreased urine output. The altered renal perfusion may be related to
       renal artery embolism, prolonged hypotension, or prolonged aortic crossclamping during surgery.
       Electrolyte imbalance and anxiety do not present imminent risk for this client; signs of wound
       infection are generally not evident immediately following surgery, but the nurse should monitor the
       incision on an ongoing basis.
       CN: Physiological adaptation; CL: Analyze

Question 87

A client underwent surgery to repair an abdominal aortic aneurysm. The surgeon made an incision that
extends from the xiphoid process to the pubis. At 12 noon 2 days after surgery, the client has
abdominal distention. The nurse checks the progress notes in the medical record, as shown below.
07/07/12 10 pm
The client is receiving D5 W 1,000ml every 8 hours. The NGtue is attached to low suction and draining well. The client has been NPO except ice chips. The client has had 10 mg morphine for pain at 6 am
E. Levine, RN

What is most likely contributing to the client’s abdominal distention?

1. Nasogastric (NG) tube.
2. Ice chips.
3. IV fluid intake.
4. Morphine.

Answer 87

87. 4. The client is experiencing paralytic ileus. One of the adverse effects of morphine used to
       manage pain is decreased GI motility. Bowel manipulation and immobility also contribute to a
       postoperative ileus. Insertion of an NG tube generally prevents a postoperative ileus. The ice chips
       and IV fluids will not affect the ileus.
       CN: Basic care and comfort; CL: Analyze

Question 88

88. A client is discharged after an aortic aneurysm repair with a synthetic graft to replace part of
    the aorta. The nurse should instruct the client to notify the physician before having:
89. Blood drawn.
90. An IV line inserted.
91. Major dental work.
92. An x-ray examination.

Answer 88

88. 3. The client with a synthetic graft may need to be treated with prophylactic antibiotics before
       undergoing major dental work. This reduces the danger of systemic infection caused by bacteria from
       the oral cavity. Venous access for drawing blood, IV line insertion, and x-rays do not contribute to the
       risk of infection.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 89

89. A client with deep vein thrombosis has been receiving warfarin (Coumadin) for 2 months.
    The client reports bleeding gums, increased bruising, and dark stools. These symptoms indicate that
    the medication:
90. Does not need to be changed.
91. Needs to be decreased.
92. Needs to be increased.
93. Is not being taken as prescribed.

Answer 89

89. 2. These symptoms suggest that the client is receiving too much Coumadin. Coumadin hinders
       the hepatic synthesis of vitamin K–dependent clotting factors and prolongs the clotting time. Because
       many factors influence the effectiveness of Coumadin, the dosage is monitored closely. Signs and
       symptoms of blood loss include bleeding gums, petechiae, bruises, dark stools, and dark urine.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 90

The Client with Stasis Ulcers
90. A well-nourished client is admitted with a stasis ulcer. The nurse assesses the ulcer and finds
excavation of the skin surface as a result of sloughing of inflammatory necrotic tissue. The physician
has prescribed the ulcer to be flushed with a fibrinolytic agent. Which of the following goals are
appropriate for this client? Select all that apply.
appropriate for this client? Select all that apply.
1. Increase oxygen to the tissues.
2. Prevent direct trauma to the ulcer.
3. Improve nutrition.
4. Prevent infection.
5. Reduce pain.

Answer 90

The Client with Stasis Ulcers
90. 1, 2, 4, 5. The underlying pathophysiology in stasis ulcers of the skin surface is a result of
inadequate oxygen and other nutrients to the tissues because of edema and decreased circulation. The
nurse should first initiate care that will increase oxygen and improve tissue integrity. It is also
important to prevent trauma to the tissues and prevent infections, which result from decreased
microcirculation that limits the body’s response to infection. Stasis ulcers are painful. The nurse can
administer prescribed analgesics 30 minutes before changing the dressing. There is no indication that
the client’s overall nutrition needs to be improved.
CN: Physiological adaptation; CL: Create

Question 91

91. A client has had a stasis ulcer of the left ankle with 2+ pitting edema for 2 years. The client is
    taking chlorothiazide. The expected outcome of this drug is:
92. Improved capillary circulation.
93. Decreased blood pressure.
94. Wound healing.
95. Absence of infection.

Answer 91

91. 1. The result of chronic venous stasis is swelling and edema and superficial varicose veins.
       Diuretics will help reduce the swelling, thus improving capillary circulation. Although diuretics maydecrease blood pressure, that is not the intended outcome of this drug. The nurse should teach the
       client to prevent infection and monitor wound healing, but these are not the primary outcomes of
       chlorothiazide.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 92

92. The nurse assesses a client with a 5 × 2 stasis ulcer just above the left malleolus. The wound
    is open with irregular, reddened, swollen edges and there is a moderate amount of yellowish tan
    drainage coming from the wound. The client verbalizes pressure-type pain and rates the discomfort at
    7 on a scale of 0 to 10. To maintain tissue integrity, the primary nursing goal should focus on:
93. Administering prescribed analgesics.
94. Applying lanolin lotions to the left ankle stasis ulcer.
95. Encouraging the client to sit up in a chair four times per day.
96. Providing an over-the-bed cradle to protect the left ankle from the pressure of bed linens

Answer 92

92. 4. Providing an over-the-bed cradle will decrease the amount of pressure that the linens exert
       upon the lower extremity and prevent further tissue breakdown. Administering prescribed analgesics
       would be an intervention for reducing the pain. Applying lanolin lotions to the left ankle ulcer will
       not promote healing. Encouraging the client to sit up in a chair four times per day is an intervention to
       promote activity. The nurse would elevate the involved extremity while the client is sitting up to
       reduce venous stasis and capillary pressure.
       CN: Health promotion and maintenance; CL: Synthesize

Question 93

93. The nurse is discharging a client with a chronic right ankle stasis ulcer. Before discharge, the
    nurse realizes that the client needs further teaching about wound care when the client:
94. Has made an appointment with a physical therapist.
95. Will apply a home herb mixture to the wound to promote healing.
96. Will need to be patient with the healing process.
97. Will eat a balanced diet.

Answer 93

93. 2. The nurse should first determine how the client will apply an herb mixture to the ulcer. The
       nurse should then encourage the client to consult the physician because home remedies may be
       beneficial or may interfere with the medical treatment plan. In many cultures, home remedies are
       commonly used and may be helpful. The nurse must be sensitive to these traditions and cultural
       beliefs. The other statements demonstrate that the client understands the plan of care for the ulcer.
       CN: Health promotion and maintenance; CL: Evaluate

Question 94

The Client with Peripheral Arterial Occlusive
Disease
94. The nurse is caring for a client who has just had an ankle-brachial index (ABI) test. The left
arm blood pressure was 160/80 mm Hg and a palpable systolic blood pressure of the left lower
extremity was 130/60 mm Hg. These findings suggest that the client has:
1. Mild peripheral artery disease.
2. Moderate peripheral artery disease.
3. No apparent occlusion in the left lower extremity.
4. Severe peripheral artery disease

Answer 94

The Client with Peripheral Arterial Occlusive Disease
94. 1. The ABI test is a noninvasive test that compares the systolic blood pressure in the arm with
that of the ankle. It may be done before or after exercise. The client’s highest brachial systolic
pressure is divided by the left ankle systolic blood pressure to get 0.81. This score is between 0.71
and 0.90, which suggests mild peripheral artery disease. Moderate peripheral artery disease would
yield a score of 0.41 to 0.70. Severe peripheral artery disease would result in a score of 0.00 to 0.40.
CN: Physiological adaptation; CL: Analyze

Question 95

95. A client is admitted for a revascularization procedure for arteriosclerosis in the left iliac
    artery. To promote circulation in the extremities, the nurse should:
96. Position the client on a firm mattress.
97. Keep the involved extremity warm with blankets.
98. Position the left leg at or below the body’s horizontal plane.
99. Encourage the client to raise and lower the leg four times every hour.

Answer 95

95. 3. Keeping the involved extremity at or below the body’s horizontal plane will facilitate tissue
       perfusion and prevent tissue damage. The nurse should avoid placing the affected extremity on a hard
       surface, such as a firm mattress, to avoid pressure ulcers. In addition, the involved extremity should
       be free from heavy overlying bed linens. The nurse should handle the involved extremity in a gentle
       fashion to prevent friction or pressure. Raising the leg would cause occlusion to the iliac artery,
       which is contrary to the goal to promote arterial circulation.
       CN: Physiological adaptation; CL: Synthesize

Question 96

96. A sedentary, obese, middle-aged client is recovering from a right iliac blood clot. The nurse
    should develop a discharge plan with the client that will focus on participating in which of the
    following activities? Select all that apply.
97. Aerobic activity.
98. Strength training.
99. Weight control.
100. Stress management.
101. Wearing supportive athletic shoes.

Answer 96

96. 1, 3. Discharge teaching begins when the client enters the hospital. One of the risk factors for
    clot formation is a sedentary lifestyle, and the client should engage in daily aerobic activity, such as
    biking or swimming (non-weight-bearing). The client is also overweight and should plan to control
    the weight through dietary counseling or attending weight management programs in the community.
    Strength training is beneficial by increasing strength and lean body mass, but not helpful in preventing
    vascular disease. Stress management is not a focus based on the client’s needs at this time. It is not
    necessary to wear special supportive shoes; comfortable shoes for walking are adequate.
    CN: Health promotion and maintenance; CL: Create

Question 97

97. The nurse is assessing the pulse in a client with aortic iliac disease. On the illustration
    below, indicate the pulse site that will give the nurse the most useful data.

Answer 97

97. The nurse should assess the femoral artery. Weak or absent femoral pulses are symptomatic ofaortoiliac disease.
    CN: Physiological adaptation; CL: Analyze

Question 98

98. A client with a history of hypertension and peripheral vascular disease underwent an
    aortobifemoral bypass graft. Preoperative medications included pentoxifylline (Trental), metoprolol
    (Toprol XL), and furosemide (Lasix). On postoperative day 1, the 12 noon vital signs are:
    Temperature 37.2°C; heart rate 132 bpm; respiratory rate 20; blood pressure 126/78. Urine output is
    50 to 70 mL/h. The hemoglobin and the hematocrit are stable. Using the SBAR (Situation-
    Background-Assessment-Recommendation) technique for communication, the nurse recommends that
    the primary care provider:
99. Continues the pentoxifylline.
100. Increases the IV fluids.
101. Restarts the metoprolol.
102. Resumes the furosemide.

Answer 98

Managing Care Quality and Safety
98. 3. The client is experiencing a rebound tachycardia from abrupt withdrawal of the beta
blocker. The beta blocker should be restarted due to the tachycardia, history of hypertension, and the
desire to reduce the risk of postoperative myocardial morbidity. The bypass surgery should correct
the claudication and need for pentoxifylline. The furosemide and increase in fluids are not indicated
since the client’s urine output and blood pressure are satisfactory and there is no indication of
bleeding. The potassium should also be assessed prior to starting the furosemide.
CN: Management of care; CL: Synthesize

Question 99

99. The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair
    2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving
    the client’s pain and the client refuses to get out of bed to ambulate as prescribed. The nurse contacts
    the physician, explains the situation, and provides information about drug dose, frequency of
    administration, the client’s vital signs, and the client’s score on the pain scale. The nurse requests a
    prescription for a different, or stronger, pain medication. The physician tells the nurse that the current
    prescription for pain medication is sufficient for this client and that the client will feel better in
    several days. The nurse should next:
100. Explain to the physician that the current pain medication and other strategies are not helping the
     client and it is making it difficult for the client to ambulate as prescribed.
101. Ask the hospitalist to write a prescription for a stronger pain medication.
102. Wait until the next shift and ask the nurse on that shift to contact the physician.
103. Report the incident to the team leader.

Answer 99

99. 1. The nurse is the client’s advocate in planning for pain relief. When presented with a
       communications conflict, the nurse should first restate the concern, providing as much information as
       needed. If the physician still does not offer an acceptable solution for pain management, the nurse can
       then discuss the situation with the hospitalist on the team and report the incident to the team leader.
       Waiting until the next shift to handle the problem does not contribute to the goal of managing the
       client’s pain.
       CN: Safety and infection control; CL: Synthesize

Question 100

100. The nurse is obtaining a blood sample for a partial thromboplastin time test prescribed for a
     client who is taking heparin. It is 5 AM when drawing the blood, the nurse should do which of the
     following? Select all that apply.
101. Awake the client.
102. Check the armband for client identification number and compare with the prescription.
103. Label the sample vial in front of the client.
104. Verify the room number with the room assignment.
105. Ask the client to state his/her name.

Answer 100

100. 1, 2, 3, 5. When obtaining blood samples, the nurse must use two acceptable sources of
     identification (the client states his/her name; the nurse verifies the client’s name and identification
     number of the armband); verifying a room number is not acceptable as client’s can be easilyreassigned to other rooms. The client must be awake to state his/her name. Blood samples must be
     labeled in front of the client.
     CN: Safety and infection control; CL: Synthesize

Question 101

101. A client has acute arterial occlusion. The physician has prescribed IV heparin. Before
     starting the medication, the nurse should:
102. Review the blood coagulation laboratory values.
103. Test the client’s stools for occult blood.
104. Count the client’s apical pulse for 1 minute.
105. Check the 24-hour urine output record.

Answer 101

101. 1. Before starting a heparin infusion, it is essential for the nurse to know the client’s baseline
        blood coagulation values (hematocrit, hemoglobin, and red blood cell and platelet counts). In
        addition, the partial thromboplastin time should be monitored closely during the process. The client’s
        stools would be tested only if internal bleeding is suspected. Although monitoring vital signs such as
        apical pulse is important in assessing potential signs and symptoms of hemorrhage or potential
        adverse reactions to the medication, vital signs are not the most important data to collect before
        administering the heparin. Intake and output are not important assessments for heparin administration
        unless the client has fluid and volume problems or kidney disease.
        CN: Safety and infection control; CL: Synthesize

Question 102

102. The nurse is caring for a client who has a below-the-knee amputation due to diabetic foot
     ulcers. The client has been somewhat confused since returning from surgery last evening but has nohistory of falls. The client is receiving intravenous antibiotics intermittently through a peripheral IV
     and has prescriptions to be up with physical therapy only. Using the Morse Fall Scale (see chart),
     what is this client’s total score and risk level?
     1.
     2.
     3.
     4.
     20, low risk.
     30, medium risk.
     40, medium risk.
     50, high risk

Answer 102

102. 4. 50, High Risk: Several variables make this client a high fall risk including secondary
        diagnosis of diabetes (15); intermittent IV antibiotics (20); and mental status changes (15) possibly
        due to anesthesia, pain, or recent limb loss. This client’s assessment may clearly change as the effects
        of anesthesia wear off, pain is controlled, and the client becomes accustomed to ambulating with a
        prosthesis; because assessments may be continually changing, in most acute care facilities, a fall risk
        is completed every 24 hours and sometimes, every shift.
        CN: Safety and infection control; CL: Apply