UNIT 4: Assessment and Management of Patients with Vascular Disorders and Peripheral Circulation Concerns

Question 1

The nurse is taking a health history of a new client who reports pain in the left lower leg
and foot when walking. This pain is relieved with rest, and the nurse observes that the left
lower leg is slightly edematous and is hairless. When planning this client’s care, the nurse
should most likely address which health problem?
A. Coronary artery disease (CAD)
B. Intermittent claudication
C. Arterial embolus
D. Raynaud disease

Answer 1

ANS: B
Rationale: A muscular, cramp-type pain in the extremities consistently reproduced with
the same degree of exercise or activity and relieved by rest is experienced by clients with
peripheral arterial insufficiency. Referred to as intermittent claudication, this pain is
caused by the inability of the arterial system to provide adequate blood flow to the tissues
in the face of increased demands for nutrients and oxygen during exercise. The nurse
would not suspect the client has CAD, arterial embolus, or Raynaud disease; none of
these health problems produce this cluster of signs and symptoms.

Question 2

While assessing a client, the nurse notes that the client’s ankle-brachial index (ABI) of
the right leg is 0.40. How should the nurse best follow up this assessment finding?
A. Assess the client’s use of over-the-counter dietary supplements.
B. Implement interventions relevant to arterial narrowing.
C. Encourage the client to increase intake of foods high in vitamin K.
D. Adjust the client’s activity level to accommodate decreased coronary output

Answer 2

ANS: B
Rationale: ABI is used to assess the degree of stenosis of peripheral arteries. An ABI of
less than 1.0 indicates possible claudication of the peripheral arteries. It does not indicate
inadequate coronary output. There is no direct indication for changes in vitamin K intake
and over-the-counter (OTC) medications are not likely causative.

Question 3

The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns
during the admission assessment that the client takes oral contraceptives. The nurse’s
postoperative plan of care should include what intervention?
A. Early ambulation and leg exercises
B. Cessation of the oral contraceptives until 3 weeks’ postoperative
C. Doppler ultrasound of peripheral circulation twice daily
D. Dependent positioning of the client’s extremities when at rest

Answer 3

ANS: A
Rationale: Oral contraceptive use increases blood coagulability; with bed rest, the client
may be at increased risk of developing deep vein thrombosis. Leg exercises and early
ambulation are among the interventions that address this risk. Assessment of peripheral
circulation is important, but Doppler ultrasound may not be necessary to obtain these
data. Dependent positioning increases the risk of venous thromboembolism (VTE).
Contraceptives are not normally discontinued to address the risk of VTE in the short
term.

Question 4

A nurse is creating an education plan for a client with venous insufficiency. Which
measure should the nurse include in the plan?
A. Avoid normal stockings that are tight.
B. Limit activities, including walking.
C. Sleep with legs below heart level.
D. Refrain from using graduated compression stockings.

Answer 4

ANS: A
Rationale: Measures taken to prevent complications include avoiding tight-fitting socks
and panty girdles; maintaining activities, such as walking; sleeping with legs elevated;
and using pressure stockings. Not included in the teaching plan for venous insufficiency
would be reducing activity, sleeping with legs dependent, and avoiding pressure
stockings. Each of these actions exacerbates venous insufficiency.

Question 5

The nurse is caring for a client with a large venous leg ulcer. What intervention should
the nurse implement to promote healing and prevent infection?
A. Provide a high-calorie, high-protein diet.
B. Apply a clean occlusive dressing once daily and whenever soiled.
C. Abstain from wearing graduated compression stockings.
D. Apply an antibiotic ointment on the surrounding skin with each dressing change.

Answer 5

ANS: A
Rationale: Wound healing is highly dependent on adequate nutrition. The diet should be
sufficiently high in calories and protein. Antibiotic ointments are not normally used on the
skin surrounding a leg ulcer and occlusive dressings can exacerbate impaired blood flow.
Compression therapy should be implemented with venous ulcers but not arterial ulcers.

Question 6

The nurse is caring for a client who is seeking care for signs and symptoms of
lymphedema. The nurse’s plan of care should prioritize which nursing diagnosis?
A. Risk for infection related to lower extremity swelling secondary to lymphedema
B. Disturbed body image related to lower extremity swelling secondary to
lymphedema
C. Ineffective health maintenance related to lower extremity swelling secondary to
lymphedema
D. Risk for deficient fluid volume related to lower extremity swelling secondary to
lymphedema

Answer 6

ANS: A
Rationale: Lymphedema, which is caused by accumulation of lymph in the tissues,
constitutes a significant risk for infection. The client’s body image is likely to be disturbed,
and the nurse should address this, but infection is a more significant threat to the client’s
physiologic well-being. Lymphedema is unrelated to ineffective health maintenance and
deficient fluid volume is not a significant risk.

Question 7

An occupational health nurse is providing an educational event and has been asked by
an administrative worker about the risk of varicose veins. Which action should the nurse
suggest as a preventive measure for varicose veins?
A. Sit with crossed legs for a few minutes each hour to promote relaxation.
B. Walk for several minutes every hour to promote circulation.
C. Elevate the legs when tired.
D. Wear snug-fitting ankle socks to decrease edema.

Answer 7

ANS: B
Rationale: A proactive approach to preventing varicose veins would be to walk for several
minutes every hour to promote circulation. Sitting with crossed legs may promote
relaxation, but it is contraindicated for clients with, or at risk for, varicose veins. Elevating
the legs only helps blood passively return to the heart and does not help maintain the
competency of the valves in the veins. Wearing tight ankle socks is contraindicated for
clients with, or at risk for, varicose veins; socks that are below the muscles of the calf do
not promote venous return the socks simply capture the blood and promote venous
stasis

Question 8

A client comes to the walk-in clinic with reports of pain in the foot following stepping on
a roofing nail 4 days ago. The client has a visible red streak running up his foot and ankle.
Which health problem should the nurse suspect?
A. Cellulitis
B. Local inflammation
C. Elephantiasis
D. Lymphangitis

Answer 8

ANS: D
Rationale: Lymphangitis is an acute inflammation of the lymphatic channels. It arises
most commonly from a focus of infection in an extremity. Usually, the infectious
organism is hemolytic streptococcus. The characteristic red streaks that extend up the
arm or the leg from an infected wound outline the course of the lymphatic vessels as they
drain. Cellulitis is caused by bacteria, which cause a generalized edema in the
subcutaneous tissues surrounding the affected area. Local inflammation would not
present with red streaks in the lymphatic channels. Elephantiasis is transmitted by
mosquitoes that carry parasitic worm larvae; the parasites obstruct the lymphatic
channels and results in gross enlargement of the limbs

Question 9

The triage nurse in the emergency department is assessing a client who reports pain
and swelling in the right lower leg. The client’s pain became much worse last night and
appeared along with fever, chills, and sweating. The client states, “I hit my leg on the car
door 4 or 5 days ago, and it has been sore ever since.” The client has a history of chronic
venous insufficiency. Which intervention should the nurse anticipate for this client?
A. Platelet transfusion to treat thrombocytopenia
B. Warfarin to treat arterial insufficiency
C. Antibiotics to treat cellulitis
D. Intravenous heparin to treat venous thromboembolism (VTE)

Answer 9

ANS: C
Rationale: Cellulitis is the most common infectious cause of limb swelling. The signs and
symptoms include acute onset of swelling, localized redness, and pain; it is frequently
associated with systemic signs of fever, chills, and sweating. The client may be able to
identify a trauma that accounts for the source of infection. Thrombocytopenia is a loss or
decrease in platelets and increases a client’s risk of bleeding; this problem would not
cause these symptoms. Arterial insufficiency would present with ongoing pain related to
activity. This client does not have signs and symptoms of VTE.

Question 10

A nurse in a long-term care facility is caring for an 83-year-old client who has a
history of heart failure (HF) and peripheral arterial disease (PAD). At present, the client is
unable to stand or ambulate. The nurse should implement measures to prevent which
complication?
A. Aortitis
B. Deep vein thrombosis
C. Thoracic aortic aneurysm
D. Raynaud disease

Answer 10

ANS: B
Rationale: Although the exact cause of venous thrombosis remains unclear, three
factors, known as Virchow triad, are believed to play a significant role in its development:
stasis of blood (venous stasis), vessel wall injury, and altered blood coagulation. This
client has venous stasis from immobility, vessel wall injury from PAD, and altered blood
coagulation from HF. The cause of aortitis is unknown, but it has no direct connection to
HF, PAD, or mobility issues. The greatest risk factors for thoracic aortic aneurysm are
atherosclerosis and hypertension; there is no direct connection to HF, PAD, or mobility issues. Raynaud disease is a disorder that involves spasms of blood vessels and, again,
no direct connection to HF, PAD, or mobility issues.

Question 11

A nurse has written a plan of care for a client diagnosed with peripheral arterial
insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue
perfusion related to compromised circulation. Which intervention is the most appropriate
for this diagnosis?
A. Elevate the legs and arms above the heart when resting.
B. Encourage the client to engage in a moderate amount of exercise.
C. Encourage extended periods of sitting or standing.
D. Discourage walking in order to limit pain

Answer 11

ANS: B
Rationale: The nursing diagnosis of altered peripheral tissue perfusion related to
compromised circulation requires interventions that focus on improving circulation.
Encouraging the client to engage in a moderate amount of exercise serves to improve
circulation. Elevating the client’s legs and arms above the heart when resting would be
passive and fails to promote circulation. Encouraging long periods of sitting or standing
would further compromise circulation. The nurse should encourage, not discourage,
walking to increase circulation and decrease pain

Question 12

The nurse is planning care for a client with venous insufficiency. Which nursing
intervention would be appropriate for this client’s plan of care?
A. Elevate lower extremities.
B. Educate on decreased protein.
C. Apply compression only at night.
D. Teach frequent rest periods due to pain.

Answer 12

ANS: A
Rationale: Venous insufficiency is lack of blood flow back to the heart. Elevation of lower
extremities will assist the peripheral blood vessels in returning stasis of blood. Increased
protein should be taught. Compression therapy should be used but not only at night. Pain
is not usually assessed in clients with venous insufficiency but with arterial insufficiency

Question 13

A nurse in the rehabilitation unit is caring for an older adult client who is in cardiac
rehabilitation following an MI. The nurse’s plan of care calls for the client to walk for 10
minutes 3 times a day. The client questions the relationship between walking and heart
function. How should the nurse best reply?
A. “The arteries in your legs constrict when you walk and allow the blood to move
faster and with more pressure on the tissue.”
B. “Walking increases your heart rate and blood pressure. Therefore, your heart is
under less stress.”
C. “Walking helps your heart adjust to your new arteries and helps build your
self-esteem.”
D. “When you walk, the muscles in your legs contract and pump the blood in your
veins back toward your heart, which allows more blood to return to your heart.”

Answer 13

ANS: D
Rationale: Veins, unlike arteries, are equipped with valves that allow blood to move
against the force of gravity. The legs have one-way bicuspid valves that prevent blood
from seeping backward as it moves forward by the muscles in our legs pressing on the
veins as we walk and increasing venous return. Leg arteries do constrict when walking,
which allows the blood to move faster and with more pressure on the tissue, but the
greater concern is increasing the flow of venous blood to the heart. Walking increases,
not decreases, the heart’s pumping ability, which increases heart rate and blood pressure
and the heart’s ability to manage stress. Walking does help the heart adjust to new
arteries and may enhance self-esteem, but the client had an MI—there are no “new
arteries.”

Question 14

The nurse is preparing to administer warfarin to a client with deep vein
thrombophlebitis. Which laboratory value would most clearly indicate that the client’s
warfarin is at therapeutic levels?
A. Partial thromboplastin time (PTT) within normal reference range
B. Prothrombin time (PT) 8 to 10 times the control
C. International normalized ratio (INR) between 2 and 3
D. Hematocrit of 32%

Answer 14

ANS: C
Rationale: The INR is most often used to determine whether warfarin is at a therapeutic
level; an INR of 2 to 3 is considered therapeutic. Warfarin is also considered to be at
therapeutic levels when the client’s PT is 1.5 to 2 times the control. Higher values indicate
increased risk of bleeding and hemorrhage, whereas lower values indicate increased
risk of blood clot formation. Heparin, not warfarin, prolongs PTT. Hematocrit does not provide
information on the effectiveness of warfarin; however, a falling hematocrit in a client
taking warfarin may be a sign of hemorrhage.

Question 15

The clinic nurse is caring for a 57-year-old client who reports experiencing leg pain
whenever walking several blocks. The client has type 1 diabetes and has smoked a pack
of cigarettes every day for the past 40 years. The health care provider diagnoses
intermittent claudication. The nurse should provide which instruction about long-term
care to the client?
A. “Be sure to practice meticulous foot care.”
B. “Consider cutting down on your smoking.”
C. “Reduce your activity level to accommodate your limitations.”
D. “Try to make sure you eat enough protein.”

Answer 15

ANS: A
Rationale: The client with peripheral vascular disease or diabetes should receive
education or reinforcement about skin and foot care. Intermittent claudication and other
chronic peripheral vascular diseases reduce oxygenation to the feet, making them
susceptible to injury and poor healing; therefore, meticulous foot care is essential. The
client should stop smoking—not just cut down—because nicotine is a vasoconstrictor.
Daily walking benefits the client with intermittent claudication. Increased protein intake
will not alleviate the client’s symptoms.

Question 16

A client who has undergone a femoral to popliteal bypass graft surgery returns to the
surgical unit. Which assessments should the nurse perform during the first postoperative
day?
A. Assess pulse of affected extremity every 15 minutes at first.
B. Palpate the affected leg for pain during every assessment.
C. Assess the client for signs and symptoms of compartment syndrome every 2
hours.
D. Perform Doppler evaluation once daily.

Answer 16

ANS: A
Rationale: The primary objective in the postoperative period is to maintain adequate
circulation through the arterial repair. Pulses, Doppler assessment, color and
temperature, capillary refill, and sensory and motor function of the affected extremity are
checked and compared with those of the other extremity; these values are recorded
initially every 15 minutes and then at progressively longer intervals if the client’s status
remains stable. Doppler evaluations should be performed every 2 hours. Pain is regularly
assessed, but palpation is not the preferred method of performing this assessment.
Compartment syndrome results from the placement of a cast, not from vascular surgery.

Question 17

The nurse is caring for a client who is diagnosed with Raynaud phenomenon. The
nurse should plan interventions to address which nursing diagnosis?
A. Chronic pain
B. Ineffective tissue perfusion
C. Impaired skin integrity
D. Risk for injury

Answer 17

ANS: B
Rationale: Raynaud phenomenon is a form of intermittent arteriolar vasoconstriction
resulting in inadequate tissue perfusion. This results in coldness, pain, and pallor of the
fingertips or toes. Pain is typically intermittent and acute, not chronic, and skin integrity
is rarely at risk. In most cases, the client is not at a high risk for injury

Question 18

A client presents to the clinic reporting the inability to grasp objects with the right
hand. The client’s right arm is cool and has a difference in blood pressure of more than 20
mm Hg compared with the left arm. The nurse should expect that the primary provider
may diagnose the client with which health problem?
A. Lymphedema
B. Raynaud phenomenon
C. Upper extremity arterial occlusive disease
D. Upper extremity venous thromboembolism (VTE)

Answer 18

ANS: C
Rationale: The client with upper extremity arterial occlusive disease typically complains
of arm fatigue and pain with exercise (forearm claudication) and inability to hold or grasp
objects (e.g., combing hair, placing objects on shelves above the head) and,
occasionally, difficulty driving. Assessment findings include coolness and pallor of the
affected extremity, decreased capillary refill, and a difference in arm blood pressures
of more than 20 mm Hg. These symptoms are not closely associated with Raynaud disease
or lymphedema. The upper extremities are rare sites for VTE.

Question 19

A nurse working in a long-term care facility is performing the admission assessment
of a newly admitted 85-year-old resident. During inspection of the resident’s feet, the
nurse notes early evidence of gangrene on one of the resident’s great toes. The nurse
should assess for further evidence of which health problem?
A. Chronic venous insufficiency
B. Raynaud phenomenon
C. Venous thromboembolism (VTE)
D. Peripheral artery disease (PAD)

Answer 19

ANS: D
Rationale: In older adults, symptoms of PAD may be more pronounced than in younger
people. In older adult clients who are inactive, gangrene may be the first sign of disease.
Venous insufficiency does not normally manifest with gangrene. Similarly, VTE and
Raynaud phenomenon do not cause the ischemia that underlies gangrene.

Question 20

The nurse is caring for an acutely ill client who is on a factor Xa inhibitor. The client
has a comorbidity of renal insufficiency. How will this client’s renal status affect this
anticoagulant therapy?
A. The factor Xa inhibitor is contraindicated in the treatment of this client.
B. The factor Xa inhibitor may be given subcutaneously, but not intravenously (IV).
C. Lower doses of factor Xa inhibitor are required for this client.
D. Warfarin will be substituted for the factor Xa inhibitor.

Answer 20

ANS: C
Rationale: If renal insufficiency exists, lower doses, not contraindication, of factor Xa
inhibitors are needed. Warfarin is not an acceptable substitution for this type of
medication. There is no contraindication for IV administration.

Question 21

The nurse is assessing a woman who is pregnant at 27 weeks’ gestation. The client is
concerned about the recent emergence of varicose veins on the backs of her calves. What
is the nurse’s best action?
A. Facilitate a referral to a vascular surgeon.
B. Assess the client’s ankle-brachial index (ABI) and perform Doppler ultrasound
testing.
C. Encourage the client to increase her activity level.
D. Teach the client that circulatory changes during pregnancy frequently cause
varicose veins.

Answer 21

ANS: D
Rationale: Pregnancy may cause varicosities because of hormonal effects related to
decreased venous outflow, increased pressure by the gravid uterus, and increased blood
volume. In most cases, no intervention or referral is necessary. This finding is not an
indication for ABI assessment and increased activity will not likely resolve the problem.

Question 22

Graduated compression stockings have been prescribed to treat a client’s venous
insufficiency. What education should the nurse prioritize when introducing this
intervention to the client?
A. The need to take anticoagulants concurrent with using compression stockings
B. The need to wear the stockings on a “one day on, one day off” schedule
C. The importance of wearing the stockings around the clock to ensure maximum
benefit
D. The importance of ensuring the stockings are applied evenly with no pressure
points

Answer 22

ANS: D
Rationale: Any type of stocking can inadvertently become a tourniquet if applied
incorrectly (i.e., rolled tightly at the top). In such instances, the stockings produce rather
than prevent stasis. For ambulatory clients, graduated compression stockings are
removed at night and reapplied before the legs are lowered from the bed to the floor in
the morning. They are used daily, not on alternating days. Anticoagulants are not always
indicated in clients who are using compression stockings.

Question 23

The nurse caring for a client with a leg ulcer has finished assessing the client and is
developing a problem list prior to writing a plan of care. What priority risk would the care
plan address?
A. Disuse syndrome
B. Ineffective health maintenance
C. Sedentary lifestyle
D. Insufficient nutrition

Answer 23

ANS: D
Rationale: The client with leg ulcers is at risk for insufficient nutrition related to the
increased need for nutrients that promote wound healing. The risk for disuse syndrome is
a state in which an individual is at risk for deterioration of body systems owing to
prescribed or unavoidable musculoskeletal inactivity. A leg ulcer will affect activity, but
rarely to this degree. Leg ulcers are not necessarily a consequence of ineffective health
maintenance or a sedentary lifestyle

Question 24

How should the nurse best position a client who has leg ulcers that are venous in
origin?
A. Keep the client’s legs flat and straight.
B. Keep the client’s knees bent to a 45-degree angle and supported with pillows.
C. Elevate the client’s lower extremities.
D. Dangle the client’s legs over the side of the bed

Answer 24

ANS: C
Rationale: Positioning of the legs depends on whether the ulcer is of arterial or venous
origin. With ulcers of venous origin, the lower extremities should be elevated to avoid
dependent edema. Simply bending the knees to a 45-degree angle would not prevent
dependent edema, as they must be elevated above the level of the heart. Dangling the
client’s legs and applying pillows may further compromise venous return.

Question 25

A client with advanced venous insufficiency is confined to bed rest following
orthopedic surgery. How can the nurse best prevent skin breakdown in the client’s lower
extremities?
A. Ensure that the client’s heels are protected and supported.
B. Closely monitor the client’s serum albumin and prealbumin levels.
C. Perform gentle massage of the client’s lower legs, as tolerated.
D. Perform passive range-of-motion exercises once per shift

Answer 25

ANS: A
Rationale: If the client is on bed rest, it is important to relieve pressure on the heels to
prevent pressure ulcerations, since the heels are among the most vulnerable body
regions. Monitoring blood work does not directly prevent skin breakdown, even though
albumin is related to wound healing. Massage is not normally indicated and may
exacerbate skin breakdown. Passive range- of-motion exercises do not directly reduce
the risk of skin breakdown.

Question 26

The nurse has performed a thorough nursing assessment of the care of a client with
chronic leg ulcers. The nurse’s assessment should include which of the following
components? Select all that apply.
A. Location and type of pain
B. Apical heart rate
C. Bilateral comparison of peripheral pulses
D. Comparison of temperature in the client’s legs
E. Identification of mobility limitations

Answer 26

ANS: A, C, D, E
Rationale: A careful nursing history and assessment are important. The extent and type
of pain are carefully assessed, as are the appearance and temperature of the skin of both
legs. The quality of all peripheral pulses is assessed, and the pulses in both legs are
compared. Any limitation of mobility and activity that results from vascular insufficiency
is identified. It is not likely that there is any direct indication for assessment of apical
heart rate, although peripheral pulses must be assessed.

Question 27

A nurse on a medical unit is caring for a client who has been diagnosed with
lymphangitis. When reviewing this client’s medication administration record, the nurse
should anticipate which type of medication?
A. An anticoagulant
B. A diuretic
C. An antibiotic
D. An antiplatelet aggregator

Answer 27

ANS: C
Rationale: Lymphangitis is an acute inflammation of the lymphatic channels caused by an
infectious process. Antibiotics are always a component of treatment. Diuretics are of
nominal use. Anticoagulants and antiplatelet aggregators are not indicated in this form of
infection.

Question 28

A postsurgical client has illuminated the call light to inform the nurse of a sudden
onset of lower leg pain. On inspection, the nurse observes that the client’s left leg is
visibly swollen and reddened. Which action by the nurse would be most appropriate?
A. Administer a PRN dose of subcutaneous heparin.
B. Inform the health care provider that the client has signs and symptoms of
venous thromboembolism (VTE).
C. Mobilize the client promptly to dislodge any thrombi in the client’s lower leg.
D. Massage the client’s lower leg to temporarily restore venous return.

Answer 28

ANS: B
Rationale: VTE requires prompt medical follow-up. Heparin will not dissolve an
established clot. Massaging the client’s leg and mobilizing the client would be
contraindicated because they would dislodge the clot, possibly resulting in a pulmonary
embolism.

Question 29

A nurse is closely monitoring a client who has recently been diagnosed with an
abdominal aortic aneurysm. What assessment finding would signal an impending rupture
of the client’s aneurysm?
A. Sudden increase in blood pressure and a decrease in heart rate
B. Cessation of pulsating in an aneurysm that has previously been pulsating visibly
C. Sudden onset of severe back or abdominal pain
D. New onset of hemoptysis

Answer 29

ANS: C
Rationale: Signs of impending rupture include severe back or abdominal pain, which may
be persistent or intermittent. Impending rupture is not typically signaled by increased
blood pressure, bradycardia, cessation of pulsing, or hemoptysis.

Question 30

A nurse is reviewing the physiologic factors that affect a client’s cardiovascular health
and tissue oxygenation. What is the systemic arteriovenous oxygen difference?
A. The average amount of oxygen removed by each organ in the body
B. The amount of oxygen removed from the blood by the heart
C. The amount of oxygen returning to the lungs via the pulmonary artery
D. The amount of oxygen in aortic blood minus the amount of oxygen in the vena
caval blood

Answer 30

ANS: D
Rationale: The average amount of oxygen removed collectively by all of the body tissues
is about 25%. This means that the blood in the vena cava contains about 25% less
oxygen than aortic blood. This is known as the systemic arteriovenous oxygen difference.
The other answers do not apply.

Question 31

The nurse is evaluating a client’s diagnosis of arterial insufficiency with reference to
the adequacy of the client’s blood flow. On what physiologic variables does adequate
blood flow depend? Select all that apply.
A. Efficiency of heart as a pump
B. Adequacy of circulating blood volume
C. Ratio of platelets to red blood cells
D. Size of red blood cells
E. Patency and responsiveness of the blood vessels

Answer 31

ANS: A, B, E
Rationale: Adequate blood flow depends on the efficiency of the heart as a pump, the
patency and responsiveness of the blood vessels, and the adequacy of circulating blood
volume. Adequacy of blood flow does not primarily depend on the size of red cells or their
ratio to the number of platelets.

Question 32

A nurse is assessing a new client who is diagnosed with peripheral artery disease. The
nurse cannot feel the pulse in the client’s left foot. How should the nurse proceed with
assessment?
A. Have the primary care provider prescribe a computed tomography (CT) scan.
B. Apply a tourniquet for 3 to 5 minutes and then reassess.
C. Elevate the extremity and attempt to palpate the pulses.
D. Use Doppler ultrasound to identify the pulses.

Answer 32

ANS: D
Rationale: When pulses cannot be reliably palpated, a hand-held continuous wave
Doppler ultrasound device may be used to hear (insonate) the blood flow in vessels. CT
is not normally warranted, and the application of a tourniquet poses health risks and will
not aid assessment. Elevating the extremity would make palpation more difficult.

Question 33

A medical nurse has admitted four clients over the course of a 12-hour shift. For
which client would assessment of ankle-brachial index (ABI) be most clearly warranted?
A. A client who has peripheral edema secondary to chronic heart failure
B. An older adult client who has a diagnosis of unstable angina
C. A client with poorly controlled type 1 diabetes who is a smoker
D. A client who has community-acquired pneumonia and a history of COPD

Answer 33

ANS: C
Rationale: Nurses should perform a baseline ABI on any client with decreased pulses or
any client 50 years of age or older with a history of diabetes or smoking. The other
answers do not apply.

Question 34

An older adult client has been treated for a venous ulcer and a plan is in place to
prevent the occurrence of future ulcers. What should the nurse include in this plan?
A. Use of supplementary oxygen to aid tissue oxygenation
B. Daily use of normal saline compresses on the lower limbs
C. Daily administration of prophylactic antibiotics
D. A high-protein diet that is rich in vitamins

Answer 34

ANS: D
Rationale: A diet that is high in protein, vitamins C and A, iron, and zinc is encouraged to
promote healing and prevent future ulcers. Prophylactic antibiotics and saline
compresses are not used to prevent ulcers. Oxygen supplementation does not prevent
ulcer formation.

Question 35

A 79-year-old client is admitted to the medical unit with digital gangrene. The client
reports that the problem first began when the client stubbed the toe going to the
bathroom in the dark. In addition to this trauma, the nurse should suspect that the client
has a history of which health problem?
A. Raynaud phenomenon
B. Coronary artery disease (CAD)
C. Arterial insufficiency
D. Varicose veins

Answer 35

ANS: C
Rationale: Arterial insufficiency may result in gangrene of the toe (digital gangrene),
which usually is caused by trauma. The toe is stubbed and then turns black. Raynaud
disease, CAD, and varicose veins are not the usual causes of digital gangrene in older
adults.

Question 36

When assessing venous disease in a client’s lower extremities, the nurse knows that
what test will most likely be prescribed?
A. Duplex ultrasonography
B. Echocardiography
C. Positron emission tomography (PET)
D. Radiography

Answer 36

ANS: A
Rationale: Duplex ultrasound may be used to determine the level and extent of venous
disease as well as its chronicity. Radiographs (x-rays), PET scanning, and
echocardiography are never used for this purpose as they do not allow visualization of
blood flow.

Question 37

The nurse is providing care for a client who has just been diagnosed with peripheral
arterial occlusive disease (PAD). What assessment finding is most consistent with this
diagnosis?
A. Numbness and tingling in the distal extremities
B. Unequal peripheral pulses between extremities
C. Visible clubbing of the fingers and toes
D. Reddened extremities with muscle atrophy

Answer 37

ANS: B
Rationale: PAD assessment may manifest as unequal pulses between extremities, with
the affected leg cooler and paler than the unaffected leg. Intermittent claudication is far
more common than sensations of numbness and tingling. Clubbing and muscle atrophy
are not associated with PAD.

Question 38

A nurse is admitting a client to the medical unit who has a history of peripheral artery
disease (PAD). While providing the health history, the client reports smoking about two
packs of cigarettes a day, having a history of alcohol abuse, and not exercising. Which
topic would be the priority health education for this client?
A. The lack of exercise, which is the main cause of PAD
B. The likelihood that heavy alcohol intake is a significant risk factor for PAD
C. The nicotine in cigarettes, which is a powerful vasoconstrictor and may cause or
aggravate PAD
D. Alcohol, which suppresses the immune system, creates high glucose levels, and
may cause PAD

Answer 38

ANS: C
Rationale: Tobacco is powerful vasoconstrictor; its use with PAD is highly detrimental,
and clients are strongly advised to stop using tobacco. Sedentary lifestyle is also a risk
factor, but smoking is likely a more significant risk factor that the nurse should address.
Alcohol use is less likely to cause PAD, although it carries numerous health risks.

Question 39

The nurse is caring for a client who is admitted to the medical unit for the treatment
of a venous ulcer in the area of the lateral malleolus that has been unresponsive to
treatment. Which finding is the nurse most likely to identify during an assessment of this
client’s wound?
A. Hemorrhage
B. Heavy exudate
C. Deep wound bed
D. Pale-colored wound bed

Answer 39

ANS: B
Rationale: Venous ulcerations in the area of the medial or lateral malleolus (gaiter area)
are typically large, superficial, and highly exudative. Venous hypertension causes
extravasation of blood, which discolors the area of the wound bed. Bleeding is not
normally present.