Chapter 36: Care of Patients with Vascular Problems Nursing School Test Banks

Chapter 36: Care of Patients with Vascular Problems
Ignatavicius: Medical-Surgical Nursing, 8th Edition

MULTIPLE CHOICE

1. A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene?
a. Assessing blood pressure in both upper extremities
b. Auscultating the carotid arteries for any bruits
c. Classifying capillary refill of 4 seconds as normal
d. Palpating both carotid arteries at the same time
ANS: D
The student should not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure should be taken and compared in both arms. Prolonged capillary refill is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits should be auscultated.

DIF: Remembering/Knowledge REF: 707
KEY: Nursing assessment| neurologic system| neurologic assessment
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning?
a. Cholesterol: 126 mg/dL
b. High-density lipoprotein cholesterol (HDL-C): 48 mg/dL
c. Low-density lipoprotein cholesterol (LDL-C): 122 mg/dL
d. Triglycerides: 198 mg/dL
ANS: D
Triglycerides in men should be below 160 mg/dL. The other values are appropriate for adult males.

DIF: Remembering/Knowledge REF: 708
KEY: Laboratory values| lipid alterations
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet?
a. A 4-ounce steak, French fries, iceberg lettuce
b. Baked chicken breast, broccoli, tomatoes
c. Fried catfish, cornbread, peas
d. Spaghetti with meat sauce, garlic bread
ANS: B
The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is the chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables.

DIF: Evaluating/Synthesis REF: 708
KEY: Nutrition| fiber| self-care
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Health Promotion and Maintenance

4. A nurse is working with a client who takes atorvastatin (Lipitor). The clients recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best?
a. Ask if the client eats grapefruit.
b. Assess the client for dehydration.
c. Facilitate admission to the hospital.
d. Obtain a random urinalysis.
ANS: A
There is a drug-food interaction between statins and grapefruit that can lead to acute kidney failure. This client has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse should assess if the client eats grapefruit or drinks grapefruit juice. Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more specific for a kidney injury. The client does not necessarily need to be admitted. A urinalysis may or may not be ordered.

DIF: Applying/Application REF: 709
KEY: Laboratory values| statins| nursing assessment| medication-food interaction
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

5. A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best?
a. Do you have trouble affording your medications?
b. Most people with hypertension do not have symptoms.
c. You are lucky; most people get severe morning headaches.
d. You need to take your medicine or you will get kidney failure.
ANS: B
Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse should explain this to the client. Asking about paying for medications is not related because the client has already admitted nonadherence. Threatening the client with possible complications will not increase compliance.

DIF: Understanding/Comprehension REF: 711
KEY: Hypertension| antihypertensive medications| medication adherence
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

6. A student nurse asks what essential hypertension is. What response by the registered nurse is best?
a. It means it is caused by another disease.
b. It means it is essential that it be treated.
c. It is hypertension with no specific cause.
d. It refers to severe and life-threatening hypertension.
ANS: C
Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension that is due to another disease process is called secondary hypertension. A severe, life-threatening form of hypertension is malignant hypertension.

DIF: Understanding/Comprehension REF: 710
KEY: Hypertension| pathophysiology| patient education
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

7. A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service?
a. African-American churches
b. Asian-American groceries
c. High school sports camps
d. Womens health clinics
ANS: A
African Americans in the United States have one of the highest rates of hypertension in the world. The nurse has the potential to reach this priority population by providing services at African-American churches. Although hypertension education and screening are important for all groups, African Americans are the priority population for this intervention.

DIF: Remembering/Knowledge REF: 711
KEY: Hypertension| primary prevention| secondary prevention| cultural awareness
MSC: Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Health Promotion and Maintenance

8. A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best?
a. Assess the clients support system.
b. Assist in finding one change the client can control.
c. Determine what stressors the client faces in daily life.
d. Inquire about delegating some of the clients obligations.
ANS: B
All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by the suggested lifestyle changes. Instead of looking at all the needed changes, the nurse should assist the client in choosing one the client feels optimistic about controlling. Once the client has mastered that change, he or she can move forward with another change. Determining support systems, daily stressors, and delegation opportunities does not directly impact the clients feelings of control.

DIF: Applying/Application REF: 712
KEY: Hypertension| patient education| coping| psychosocial response
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Psychosocial Integrity

9. The nurse is caring for four hypertensive clients. Which druglaboratory value combination should the nurse report immediately to the health care provider?
a. Furosemide (Lasix)/potassium: 2.1 mEq/L
b. Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L
c. Spironolactone (Aldactone)/potassium: 5.1 mEq/L
d. Torsemide (Demadex)/sodium: 142 mEq/L
ANS: A
Lasix is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and should be reported immediately. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. A potassium level of 5.1 mEq/L is on the high side, but it is not as critical as the low potassium with furosemide. The other two laboratory values are normal.

DIF: Applying/Application REF: 714
KEY: Hypertension| antihypertensive medications| laboratory values
MSC: Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

10. A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information?
a. Could you walk further than that a few months ago?
b. Do you walk mostly uphill, downhill, or on flat surfaces?
c. Have you ever considered swimming instead of walking?
d. How much pain medication do you take each day?
ANS: A
As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain free indicates the clients disease is worsening. The other questions are useful, but not as important.

DIF: Applying/Application REF: 719
KEY: Pain| exercise| activity| peripheral vascular disease| pain assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

11. An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care?
a. I nearly always wear comfy sweatpants and house shoes.
b. Im glad I get energy assistance so my house isnt so cold.
c. My daughter makes sure I have plenty of lotion for my feet.
d. My hands shake when I try to do things requiring coordination.
ANS: D
Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails. The nurse should refer this client to a podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for clients with PVD. Keeping the house at a comfortable temperature makes it less likely the client will use alternative heat sources, such as heating pads, to stay warm. The client should keep the feet moist and soft with lotion.

DIF: Analyzing/Analysis REF: 725
KEY: Peripheral vascular disease| self-care| home safety
MSC: Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Health Promotion and Maintenance

12. A client is taking warfarin (Coumadin) and asks the nurse if taking St. Johns wort is acceptable. What response by the nurse is best?
a. No, it may interfere with the warfarin.
b. There isnt any information about that.
c. Why would you want to take that?
d. Yes, it is a good supplement for you.
ANS: A
Many foods and drugs interfere with warfarin, St. Johns wort being one of them. The nurse should advise the client against taking it. The other answers are not accurate.

DIF: Understanding/Comprehension REF: 733
KEY: Anticoagulants| herbs and supplements| medication-food interactions| patient education MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

13. A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best?
a. No, women should only have one beer a day as a general rule.
b. No, you should not drink any alcohol with hypertension.
c. Yes, since you are larger, you can have more alcohol.
d. Yes, two beers per day is an acceptable amount of alcohol.
ANS: A
Alcohol intake should be limited to two drinks a day for men and one drink a day for women. A drink is classified as one beer, 1.5 ounces of hard liquor, or 5 ounces of wine. Limited alcohol intake is acceptable with hypertension. The womans size does not matter.

DIF: Understanding/Comprehension REF: 712
KEY: Hypertension| lifestyle choices| patient education
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance

14. A nurse is caring for four clients. Which one should the nurse see first?
a. Client who needs a beta blocker, and has a blood pressure of 92/58 mm Hg
b. Client who had a first dose of captopril (Capoten) and needs to use the bathroom
c. Hypertensive client with a blood pressure of 188/92 mm Hg
d. Client who needs pain medication prior to a dressing change of a surgical wound
ANS: B
Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse should see this client first to prevent falling if the client decides to get up without assistance. The two blood pressure readings are abnormal but not critical. The nurse should check on the client with higher blood pressure next to assess for problems related to the reading. The nurse can administer the beta blocker as standards state to hold it if the systolic blood pressure is below 90 mm Hg. The client who needs pain medication prior to the dressing change is not a priority over client safety and assisting the other client to the bathroom.

DIF: Analyzing/Analysis REF: 716
KEY: Hypertension| angiotensin-converting enzyme (ACE) inhibitors| antihypertensive medications| patient safety
MSC: Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

15. A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met?
a. Pain rated as 2/10 after medication
b. Distal pulse on affected extremity 2+/4+
c. Remains on bedrest as directed
d. Verbalizes understanding of procedure
ANS: B
Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4+ indicates good perfusion. Pain control, remaining on bedrest as directed after the procedure, and understanding are all important, but do not take priority over perfusion.

DIF: Evaluating/Synthesis REF: 722
KEY: Peripheral vascular disease| perfusion| nursing assessment
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

16. A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority?
a. Administer pain medication as ordered.
b. Assess distal pulses and skin color.
c. Document the findings in the clients chart.
d. Notify the surgeon immediately.
ANS: B
Once perfusion has been restored or improved to an extremity, clients can often feel a throbbing pain due to the increased blood flow. However, it is important to differentiate this pain from ischemia. The nurse should assess for other signs of perfusion, such as distal pulses and skin color/temperature. Administering pain medication is done once the nurse determines the clients perfusion status is normal. Documentation needs to be thorough. Notifying the surgeon is not necessary.

DIF: Applying/Application REF: 724
KEY: Peripheral vascular disease| pain assessment| nursing process assessment| postoperative nursing
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

17. A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection?
a. Appropriate hand hygiene before giving care
b. Assessing the clients temperature every 4 hours
c. Clean technique when changing dressings
d. Monitoring the clients daily white blood cell count
ANS: A
Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes should be done with sterile technique. Assessing vital signs and white blood cell count will not prevent infection.

DIF: Applying/Application REF: 724
KEY: Infection control| hand hygiene| wound infection
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

18. A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority?
a. Assess the clients neurologic status.
b. Notify the Rapid Response Team.
c. Prepare to administer vitamin K.
d. Turn down the infusion rate.
ANS: B
Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic signs may indicate the client is having a hemorrhagic stroke. The nurse does need to complete a thorough neurological examination, but should first call the Rapid Response Team based on the clients manifestations. The nurse notifies the Rapid Response Team first. Vitamin K is not the antidote for this drug. Turning down the infusion rate will not be helpful if the client is still receiving any of the drug.

DIF: Applying/Application REF: 726
KEY: Critical rescue| Rapid Response Team| medical emergencies| fibrinolytic agents
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

19. A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene?
a. Assesses the client for back pain
b. Auscultates over abdominal bruit
c. Measures the abdominal girth
d. Palpates the abdomen in four quadrants
ANS: D
Abdominal aneurysms should never be palpated as this increases the risk of rupture. The registered nurse should intervene when the student attempts to do this. The other actions are appropriate.

DIF: Applying/Application REF: 726
KEY: Aneurysms| nursing process assessment| supervision| abdominal assessment
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

20. A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met?
a. Ambulates with assistance
b. Oxygen saturation of 98%
c. Pain of 2/10 after medication
d. Verbalizing risk factors
ANS: B
A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred. The other assessments are also positive, but not the priority.

DIF: Analyzing/Analysis REF: 729
KEY: Pulmonary embolism| deep vein thrombosis| respiratory assessment| thromboembolic event MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

21. A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?
a. Ambulate the client.
b. Apply a warm moist pack.
c. Massage the clients leg.
d. Provide an ice pack.
ANS: B
Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the clients legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT.

DIF: Understanding/Comprehension REF: 731
KEY: Thromboembolic event| deep vein thrombosis| comfort measures| nonpharmacologic comfort interventions| unlicensed assistive personnel (UAP)
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

22. A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein thrombosis. The client has lost 20 pounds since the last visit. What action by the nurse is best?
a. Ask if the weight loss was intended.
b. Encourage a high-protein, high-fiber diet.
c. Measure for new compression stockings.
d. Review a 3-day food recall diary.
ANS: C
Compression stockings must fit correctly in order to work. After losing a significant amount of weight, the client should be re-measured and new stockings ordered if needed. The other options are appropriate, but not the most important.

DIF: Applying/Application REF: 731
KEY: Thromboembolic event| deep vein thrombosis| nursing assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

23. A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal?
a. Teach high school students heart-healthy living.
b. Participate in blood pressure screenings at the mall.
c. Provide pamphlets on heart disease at the grocery store.
d. Set up an Ask the nurse booth at the pet store.
ANS: B
An important goal of HP2020 is to increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high. Participating in blood pressure screening in a public spot will best help meet that goal. The other options are all appropriate but do not specifically help meet a goal.

DIF: Applying/Application REF: 711
KEY: Hypertension| primary prevention
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Health Promotion and Maintenance

24. A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin (Coumadin). The client is adamant about refusing the drug because its dangerous. What action by the nurse is best?
a. Assess the reason behind the clients fear.
b. Remind the client about laboratory monitoring.
c. Tell the client drugs are safer today than before.
d. Warn the client about consequences of noncompliance.
ANS: A
The first step is to assess the reason behind the clients fear, which may be related to the experience of someone the client knows who took warfarin. If the nurse cannot address the specific rationale, teaching will likely be unsuccessful. Laboratory monitoring once every few weeks may not make the client perceive the drug to be safe. General statements like drugs are safer today do not address the root cause of the problem. Warning the client about possible consequences of not taking the drug is not therapeutic and is likely to lead to an adversarial relationship.

DIF: Applying/Application REF: 709
KEY: Psychosocial response| anticoagulants| therapeutic communication| patient-centered care MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Psychosocial Integrity

25. A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril (Prinivil) and warfarin (Coumadin). The client reports new-onset cough. What action by the nurse is most appropriate?
a. Assess the clients lung sounds and oxygenation.
b. Instruct the client on another antihypertensive.
c. Obtain a set of vital signs and document them.
d. Remind the client that cough is a side effect of Prinivil.
ANS: A
This client could be having an exacerbation of heart failure or be experiencing a side effect of lisinopril (and other angiotensin-converting enzyme inhibitors). The nurse should assess the clients lung sounds and other signs of oxygenation first. The client may or may not need to switch antihypertensive medications. Vital signs and documentation are important, but the nurse should assess the respiratory system first. If the cough turns out to be a side effect, reminding the client is appropriate, but then more action needs to be taken.

DIF: Applying/Application REF: 715
KEY: Nursing assessment| angiotensin-converting enzyme (ACE) inhibitors| heart failure| adverse effects MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

26. A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best?
a. Consult with the Wound Ostomy Care Nurse.
b. Give pain medication prior to dressing changes.
c. Maintain sterile technique for dressing changes.
d. Prepare the client for eventual amputation.
ANS: A
A nonhealing wound needs the expertise of the Wound Ostomy Care Nurse (or Wound Ostomy Continence Nurse). Premedicating prior to painful procedures and maintaining sterile technique are helpful, but if the wound is not healing, more needs to be done. The client may need an amputation, but other options need to be tried first.

DIF: Applying/Application REF: 734
KEY: Peripheral vascular disease| consultation| wound care
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

27. A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities?
a. I can use a heating pad on my legs if its set on low.
b. I should not cross my legs when sitting or lying down.
c. I will go out and buy some warm, heavy socks to wear.
d. Its going to be really hard but I will stop smoking.
ANS: A
Clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result. The other statements show good understanding of self-management.

DIF: Evaluating/Synthesis REF: 722
KEY: Peripheral arterial disease| patient education| patient safety
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Health Promotion and Maintenance

28. A client presents to the emergency department with a severely lacerated artery. What is the priority action for the nurse?
a. Administer oxygen via non-rebreather mask.
b. Ensure the client has a patent airway.
c. Prepare to assist with suturing the artery.
d. Start two large-bore IVs with normal saline.
ANS: B
Airway always takes priority, followed by breathing and circulation. The nurse ensures the client has a patent airway prior to providing any other care measures.

DIF: Applying/Application REF: 736
KEY: Critical rescue| primary survey| trauma
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

29. The nurse is assessing a client on admission to the hospital. The clients leg appears as shown below:

What action by the nurse is best?
a. Assess the clients ankle-brachial index.
b. Elevate the clients leg above the heart.
c. Obtain an ice pack to provide comfort.
d. Prepare to teach about heparin sodium.
ANS: A
This client has dependent rubor, a classic finding in peripheral arterial disease. The nurse should measure the clients ankle-brachial index. Elevating the leg above the heart will further impede arterial blood flow. Ice will cause vasoconstriction, also impeding circulation and perhaps causing tissue injury. Heparin sodium is not the drug of choice for this condition.

DIF: Applying/Application REF: 720
KEY: Peripheral vascular disease| nursing assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE

1. What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.)
a. Administering mild analgesics for pain
b. Applying elastic compression stockings
c. Elevating the legs when sitting or lying
d. Reminding the client to do leg exercises
e. Teaching the client about surgical options
ANS: B, C, D
The three Es of care for varicose veins include elastic compression hose, exercise, and elevation. Mild analgesics are not a nonpharmacologic measure. Teaching about surgical options is not a comfort measure.

DIF: Understanding/Comprehension REF: 736
KEY: Peripheral vascular disease| nonpharmacologic comfort measures
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

2. A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Administering preoperative medication
b. Ensuring the consent is signed
c. Marking pulses with a pen
d. Raising the siderails on the bed
e. Recording baseline vital signs
ANS: D, E
The UAP can raise the siderails of the bed for client safety and take and record the vital signs. Administering medications, ensuring a consent is on the chart, and marking the pulses for later comparison should be done by the registered nurse. This is also often done by the postanesthesia care nurse and is part of the hand-off report.

DIF: Applying/Application REF: 723
KEY: Delegation| preoperative nursing| patient safety| unlicensed assistive personnel (UAP) MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

3. A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention? (Select all that apply.)
a. Apply compression stockings.
b. Assist with ambulation.
c. Encourage coughing and deep breathing.
d. Offer fluids frequently.
e. Teach leg exercises.
ANS: A, B, D
The UAP can apply compression stockings, assist with ambulation, and offer fluids frequently to help prevent DVT. The UAP can also encourage the client to do pulmonary exercises, but these do not decrease the risk of DVT. Teaching is a nursing function.

DIF: Applying/Application REF: 731
KEY: Deep vein thrombosis| delegation| unlicensed assistive personnel (UAP)
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

4. A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the clients plan of care? (Select all that apply.)
a. Assess the client for bleeding.
b. Monitor the daily activated partial thromboplastin time (aPTT) results.
c. Stop the IV for aPTT above baseline.
d. Use an IV pump for the infusion.
e. Weigh the client daily on the same scale.
ANS: A, B, D
Assessing for bleeding, monitoring aPTT, and using an IV pump for the infusion are all important safety measures for heparin to prevent injury from bleeding. The aPTT needs to be 1.5 to 2 times normal in order to demonstrate that the heparin is therapeutic. Weighing the client is not related.

DIF: Applying/Application REF: 731
KEY: Anticoagulants| patient safety| injury prevention
MSC: Integrated Process: Nursing Process: Intervention
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

5. A client is being discharged on warfarin (Coumadin) therapy. What discharge instructions is the nurse required to provide? (Select all that apply.)
a. Dietary restrictions
b. Driving restrictions
c. Follow-up laboratory monitoring
d. Possible drug-drug interactions
e. Reason to take medication
ANS: A, C, D, E
The Joint Commissions Core Measures state that clients being discharged on warfarin need instruction on follow-up monitoring, dietary restrictions, drug-drug interactions, and reason for compliance. Driving is typically not restricted.

DIF: Remembering/Knowledge REF: 733
KEY: Patient safety| Core Measures| anticoagulants| patient education
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

6. Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.)
a. A good abrasive pumice stone will keep my feet soft.
b. Ill always wear shoes if I can buy cheap flip-flops.
c. I will keep my feet dry, especially between the toes.
d. Lotion is important to keep my feet smooth and soft.
e. Washing my feet in room-temperature water is best.
ANS: C, D, E
Good foot care includes appropriate hygiene and injury prevention. Keeping the feet dry; wearing good, comfortable shoes; using lotion; washing the feet in room-temperature water; and cutting the nails straight across are all important measures. Abrasive material such as pumice stones should not be used. Cheap flip-flops may not fit well and wont offer much protection against injury.

DIF: Evaluating/Synthesis REF: 725
KEY: Peripheral vascular disease| injury prevention| patient education
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

7. A nurse is caring for a client with a nonhealing arterial ulcer. The physician has informed the client about possibly needing to amputate the clients leg. The client is crying and upset. What actions by the nurse are best? (Select all that apply.)
a. Ask the client to describe his or her current emotions.
b. Assess the client for support systems and family.
c. Offer to stay with the client if he or she desires.
d. Relate how smoking contributed to this situation.
e. Tell the client that many people have amputations.
ANS: A, B, C
When a client is upset, the nurse should offer self by remaining with the client if desired. Other helpful measures include determining what and whom the client has for support systems and asking the client to describe what he or she is feeling. Telling the client how smoking has led to this situation will only upset the client further and will damage the therapeutic relationship. Telling the client that many people have amputations belittles the clients feelings.

DIF: Applying/Application REF: 725
KEY: Psychosocial response| coping| support| therapeutic communication
MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity

8. The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply.)
a. Atherosclerosis
b. Down syndrome
c. Frequent heartburn
d. History of hypertension
e. History of smoking
ANS: A, D, E
Atherosclerosis, hypertension, hyperlipidemia, and smoking are the most common related factors. Down syndrome and heartburn have no relation to aneurysm formation.

DIF: Remembering/Knowledge REF: 726
KEY: Peripheral vascular disorders| pathophysiology
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

9. A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the clients blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.)
a. Administer pain medication.
b. Assess distal pulses every 10 minutes.
c. Have the client sign a surgical consent.
d. Notify the Rapid Response Team.
e. Take vital signs every 10 minutes.
ANS: B, D, E
This client may have a ruptured/rupturing aneurysm. The nurse should notify the Rapid Response team and perform frequent client assessments. Giving pain medication will lower the clients blood pressure even further. The nurse cannot have the client sign a consent until the physician has explained the procedure.

DIF: Applying/Application REF: 727
KEY: Critical rescue| Rapid Response Team| medical emergencies
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

SHORT ANSWER

1. A nurse is caring for a client who weighs 220 pounds and is started on enoxaparin (Lovenox). How much enoxaparin does the nurse anticipate administering? (Record your answer using a whole number.) _____ mg

ANS:
90 mg
The dose of enoxaparin is 1 mg/kg body weight, not to exceed 90 mg. This client weighs 220 pounds (110 kg), and so will get the maximal dose.

DIF: Applying/Application REF: 732
KEY: Anticoagulants| medication administration
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

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