Chapter 38: Care of Patients with Vascular Problems Nursing School Test Banks

Chapter 38: Care of Patients with Vascular Problems

Test Bank

MULTIPLE CHOICE

1. A client with atherosclerosis asks a nurse which factors are responsible for this condition. What is the nurses best response?

a.

Injury to the arteries causes them to spasm, reducing blood flow to the extremities.

b.

Excess fats in your diet are stored in the lining of your arteries, causing them to constrict.

c.

A combination of platelets and fats accumulates, narrowing the artery and reducing blood flow.

d.

Excess sodium causes injury to the arteries, reducing blood flow and eventually causing obstruction.

ANS: C

Most researchers believe that a combination of platelet and lipid accumulation following intimal injury is responsible for the process of atherosclerosis.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 773

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Teaching/Learning

2. The nurse is working with clients at a health fair. Which teaching takes priority to reduce the risk of atherosclerosis?

a.

Instructing a diabetic client not to smoke or use any tobacco

b.

Teaching diet changes to a client with elevated cholesterol levels

c.

Suggesting limiting alcohol to an older client with hypolipidemia

d.

Encouraging exercise to an obese client who lives a sedentary lifestyle

ANS: A

Atherosclerosis can be caused by mechanical and/or chemical injury. People with diabetes often have premature, severe atherosclerosis from elevated low-density lipoprotein (LDL) levels and intimal injury from hyperglycemia. Cigarette smoking or other tobacco use releases toxins into the bloodstream and causes vasoconstriction, further contributing to intimal injury. This would be the priority teaching intervention, although all teaching would be appropriate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

3. A client with hyperlipidemia who is being treated with dietary fat restrictions and an exercise program asks the nurse why his serum lipid levels are still elevated. What activity by the nurse is most appropriate?

a.

Developing a very low-fat diet that the client will adhere to

b.

Explaining familial tendencies in hyperlipidemia

c.

Referring the client to a registered dietitian for weight loss

d.

Educating the client on antihyperlipidemic medications

ANS: B

The liver of clients with familial hyperlipidemia makes excessive cholesterol and other fats. If the client is compliant with the treatment regimen and problems persist, a familial problem may exist. The client is already on a low-fat diet and exercise program, so further refining the diet and counseling for weight loss is redundant. The nurse might want to explore medications with the client, but education is premature until familial hyperlipidemia has been explored.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Teaching/Learning

4. A client with atherosclerosis is attempting to stop cigarette smoking with the use of a nicotine patch. Which statement by the client indicates a good understanding of smoking cessation education?

a.

Abruptly discontinuing this patch can cause high blood pressure.

b.

Abruptly discontinuing this patch can cause nausea and vomiting.

c.

Smoking while using this patch increases the risk of respiratory infection.

d.

Smoking while using this patch increases the risk of a heart attack.

ANS: D

Nicotine constricts blood vessels, increases mean arterial pressure, and increases afterload. Smoking while using a nicotine patch increases afterload to such an extent that the myocardium must work harder, with coronary arteries constricted. This may cause a myocardial infarction.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Nursing Process (Implementation)

5. A client with hypercholesterolemia and atherosclerosis is prescribed nicotinic acid (Niaspan). Which instruction does the nurse provide the client?

a.

This medication may make you flush.

b.

Take this medication on an empty stomach.

c.

You will not need to change your diet with this medication.

d.

Take this medication when you experience chest pain.

ANS: A

Nicotinic acid causes increased release of prostaglandins, resulting in vasodilation. Clients may experience flushing and a very warm feeling all over. Taking the drug with meals minimizes this side effect. The medication will not take the place of adjusting the diet and exercising. Nicotinic acid is not used to treat acute chest pain.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 775

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Implementation)

6. The nurse incorporates dietary teaching into the plan for a client with a low-density lipoprotein (LDL) level of 158 mg/dL. What dietary instruction by the nurse is most appropriate?

a.

You should keep your saturated fat intake below 10% of your total calories.

b.

This result is normal, so continue your current dietary practices.

c.

Your total cholesterol intake should be less than 300 mg/day.

d.

You should restrict protein sources to fish and chicken only.

ANS: A

An LDL level of 158 mg/dL is borderline high. American Heart Association (AHA) dietary guidelines advise clients to have a total saturated fat intake of less than 10% of the total caloric intake. A decrease in saturated fat intake is considered more important than decreasing the total cholesterol number because saturated fat is a main determinant of cholesterol synthesis in the body. Teaching the client the best sources of low-fat protein is a good idea, but this is too vague by itself to be the best answer. The client needs more specific information on managing the diet to keep the LDL from becoming even higher.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

7. The nurse is assisting the hospitalized client with his food selections for breakfast. The client is on a low-cholesterol diet. What recommendations are most appropriate for this client?

a.

Cheese omelet, skim milk, whole wheat toast, coffee

b.

Skim milk, oatmeal, banana, orange juice, coffee

c.

Whole wheat French toast, a side of bacon, coffee

d.

Blueberry muffin, orange juice, decaffeinated coffee

ANS: B

Cholesterol is found in animal-based products such as milk, eggs, and cheese. It is also found in baked goods such as muffins. The cheese omelet, bacon, and muffin are too high in cholesterol.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Basic Care and ComfortNutrition and Oral Hydration) MSC: Integrated Process: Nursing Process (Implementation)

8. The nurse is reviewing the menu selections of a client who has ordered a low-cholesterol diet. What meal items does the nurse question?

a.

Vegetarian wrap

b.

Cheesesteak sandwich

c.

Fruit salad with yogurt

d.

Grilled fish sandwich

ANS: B

In collaboration with the dietitian, educate the client about the types of fat content in food. Meats and eggs contain mostly saturated fats, and their intake should be limited. Cholesterol is also found in animal sources, such as meats and eggs.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Basic Care and ComfortNutrition and Oral Hydration) MSC: Integrated Process: Nursing Process (Implementation)

9. After reviewing the clients chart upon admission to the unit, the nurse consults the health care provider about a new order for lovastatin (Mevacor). What triggered the nurses action?

a.

Blood glucose of 182 mg/dL

b.

History of peptic ulcers

c.

History of high cholesterol

d.

Elevated liver enzymes

ANS: D

Treatment with any of the statins for elevated cholesterol and low-density lipoprotein (LDL) levels is contraindicated for clients with active liver disease because these agents can cause increases in liver function. No contraindications to the administration of statins to clients with diabetes mellitus, peptic ulcer disease, or rheumatoid arthritis are known.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Analysis)

10. A client with high cholesterol is beginning treatment with simvastatin (Zocor). What priority instruction does the nurse give this client?

a.

Increase your intake of dietary fiber to minimize constipation.

b.

Take this drug on an empty stomach to promote absorption.

c.

Report any muscle tenderness to your health care provider.

d.

You may experience flushing of the skin with this medication.

ANS: C

This class of drugs can cause myopathy. Muscle tenderness should be reported to the clients health care provider. HMG-CoA (3-hydroxy-3-methylglutaryl coenzyme A) reductase inhibitors do not usually cause constipation. It is not recommended that the drug be taken on an empty stomach. Flushing occurs with niacin but not typically with this class of medications.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Teaching/Learning

11. A client has been diagnosed with Cushings syndrome. What assessment does the nurse perform to detect vascular complications associated with this illness?

a.

Auscultation of heart and lung sounds

b.

Assessment of blood pressure

c.

Daily weight using the same scale

d.

Monitoring of urine output every 24 hours

ANS: B

Dysfunction of the adrenal medulla or the adrenal cortex can cause secondary hypertension. In Cushings syndrome, excessive glucocorticoids are excreted from the adrenal cortex. These excessive glucocorticoids cause increased sodium and water retention, which may lead to an increase in blood pressure. No changes in lung sounds are associated.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

12. The nurse is providing care for a client with hypertension. What priority physical assessment does the nurse include in examination of this client?

a.

Skin examination for telangiectasia

b.

Otoscopic examination of the inner ear

c.

Funduscopic examination of the retina

d.

Neurologic examination of the cranial nerves

ANS: C

The physical examination of a client with hypertension should include examination of the retina because the appearance of the retina is a reliable index of the severity of hypertension. Telangiectasia is caused by permanent dilation of small blood vessels and is not associated with hypertension. No changes in ear or cranial nerves secondary to hypertension are noted.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

13. The nurse is caring for a client with newly diagnosed hypertension. What statement by the client indicates adequate understanding of his or her diet restrictions?

a.

I will give my canned soups to the food pantry.

b.

Im going to miss my evening glass of wine.

c.

I will mostly use salt substitutes for flavoring.

d.

I can have regular coffee only in the morning.

ANS: A

Canned and processed foods can contain high levels of sodium and should be avoided. Salt substitutes contain potassium and should not be used freely, especially if the client has kidney impairment. The client is advised to refrain from cooking with salt or adding salt to food at the table and is instructed to limit (not eliminate all) alcohol intake.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care)

MSC: Integrated Process: Teaching/Learning

14. The nurse is assessing a clients understanding of his hypertension therapy. What client statement indicates a need for further teaching?

a.

If I lose weight, I might be able to reduce my blood pressure medication.

b.

If my blood pressure stays under control, I will reduce my risk for a heart attack.

c.

When my blood pressure is normal, I will no longer need to take medication.

d.

When getting out of bed in the morning, I will sit for a few moments then stand.

ANS: C

Compliance with antihypertensive therapy is difficult for two reasons. First, often clients have no distressing symptoms associated with hypertension and may not believe that they have a problem. Second, many clients believe that once blood pressure is brought back into the normal range, they are cured and no longer need to take medication. Losing weight might allow the client to reduce medications. Lowering blood pressure does lower risk for heart attack. Because blood pressure medications often lead to orthostatic hypotension, clients should be taught to change position slowly, sitting first before standing after lying flat.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Teaching/Learning

15. A nurse is about to administer the first dose of captopril (Capoten) to a client with hypertension. Which is the priority nursing intervention?

a.

Take the clients apical pulse for 1 full minute before drug administration.

b.

Place the client in Trendelenburg position to facilitate blood flow to the heart.

c.

Educate the client to sit on the side of the bed for a few minutes before rising.

d.

Instruct the client to drink 3 L of fluid daily when taking this medication.

ANS: C

Angiotensin-converting enzyme (ACE) inhibitors such as captopril can cause severe hypotension with initial use. The client should be instructed to rise slowly and sit on the side of the bed for a few minutes to prevent hypotension-induced falls. No indication is known for assessment of the apical pulse for 1 full minute before taking captopril. Placing the client in a Trendelenburg position is not indicated. In case of a precipitous drop in blood pressure, a modified Trendelenburg position may be used. Adequate fluid intake is necessary but is not the priority in this situation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes)

MSC: Integrated Process: Nursing Process (Implementation)

16. The nurse is a assessing a client with hypertension. Which client outcome is indicative of effective hypertension management?

a.

Pedal edema is not present in the lower legs.

b.

No complaints of sexual dysfunction occur.

c.

No indication of renal impairment is present.

d.

The blood pressure reading is 148/94 mm Hg.

ANS: C

One expected outcome for a client with hypertension is for the client to have no evidence of target organ damage, such as renal or heart disease, that can occur with poorly managed hypertension. Development of pedal edema is not directly related to the management of hypertension. Side effects of some hypertensive agents may interfere with sexual function, but this does not relate to the effectiveness of treatment for hypertension. The blood pressure reading is too high to demonstrate effective management.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Evaluation)

17. The nurse is assessing a client who reports claudication after walking a distance of one block. The nurse notes a painful ulcer on the fourth toe of the clients right foot. What condition do these findings correlate with?

a.

Diabetic foot ulceration

b.

Peripheral arterial disease

c.

Peripheral venous disease

d.

Deep vein thrombosis

ANS: B

Arterial disease is characterized by claudication after walking short distances. Ulcerations caused by peripheral arterial disease are painful and initially are located at the most distal points on the extremity. Diabetic ulcers and venous ulcers are seldom painful and usually tend to occur where pressure is applied.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 786

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

18. The nurse notes a venous ulcer on the clients left ankle. What additional assessment finding does the nurse expect in this client?

a.

Absence of hair on the left lower extremity

b.

Skin surrounding the ulcer mottled but blanchable

c.

Brownish discoloration of the lower extremity

d.

Cold and gray-blue lower extremity

ANS: C

Venous ulcers are characterized by brown pigmentation of the skin of the lower extremity. Mottled skin, the presence of dependent rubor, and cyanosis are features of arterial ulcers.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

19. A client with chronic peripheral arterial disease and claudication tells the nurse that burning pain often awakens him from sleep. What is the nurses interpretation of this change?

a.

The client has inflow disease.

b.

The client has outflow disease.

c.

The clients disease is worsening.

d.

The clients disease is stable.

ANS: C

Claudication is stage II of chronic peripheral arterial disease. In stage III, clients commonly experience pain while resting that awakens them at night. Clients with inflow disease experience discomfort in the lower back, buttocks, or thighs. Clients with outflow disease describe burning or cramping in the calves, ankles, feet, and toes associated with activity. Pain at rest is a sign that the disease is progressing and perfusion is altered, even with no activity.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 786

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

20. The nurse is educating a client before a right leg atherectomy. What priority education does the nurse provide?

a.

You may use the bathroom after the procedure.

b.

You will be sedated for 6 hours after the procedure.

c.

You will not need to take a daily aspirin anymore.

d.

You may be on heparin during the procedure.

ANS: D

Heparin is often used during this procedure to prevent blood clots. The client will be on bedrest for some time following the procedure so will not be able to get to the bathroom right afterward. The client will not be sedated for 6 hours postprocedure, and aspirin probably will still be part of the clients medication regimen.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 789

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Analysis)

21. The nurse is caring for a client with peripheral arterial disease. What priority nursing intervention does the nurse perform to promote vasodilation?

a.

Increase the clients exercise regimen daily.

b.

Apply a heating pad to the affected limb.

c.

Administer an aspirin on a daily basis.

d.

Educate the client to abstain from smoking.

ANS: D

Smoking causes vasoconstriction, and its effects can last up to 1 hour after the cigarette is finished. Increasing activity may lead to collateral circulation but does not cause vasodilation. Use of a heating pad is contraindicated in the client with peripheral artery disease because of the risk of a burn caused by diminished sensation. The use of aspirin my impede platelet clumping and is contraindicated only when the client is on anticoagulants.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Teaching/Learning

22. The nurse is recovering a client with peripheral arterial disease who has just undergone percutaneous transluminal angioplasty. What complication does the nurse monitor for in the immediate postprocedure period?

a.

Bleeding

b.

Aspiration

c.

Hypertensive crisis

d.

Chest pain

ANS: A

For this procedure, a catheter is advanced through a cannula inserted through the femoral artery. The nurse must monitor the client for bleeding at the puncture site.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Assessment)

23. The nurse is monitoring a client who has returned to the unit after arterial revascularization. The client reports pain in the affected limb that is similar to the pain experienced before the procedure. What is the nurses best action?

a.

Assess the peripheral pulses in the limb.

b.

Elevate the affected extremity on pillows.

c.

Administer pain medication as prescribed.

d.

Place a warm blanket on the operative limb.

ANS: A

Ischemic pain may be present because the graft is occluded. The nurse would assess the limb for peripheral pulses and would notify the surgeon if pulses are not found. Graft occlusion is a surgical emergency, and the nurse must recognize this as a sign of graft occlusion. Elevating the extremity would further compromise blood flow. Covering the extremity or administering pain addresses only the clinical manifestations, not the cause, of compromised blood flow.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential)

MSC: Integrated Process: Nursing Process (Implementation)

24. A client is recovering after an embolectomy. What clinical manifestations consistent with compartment syndrome does the nurse watch for?

a.

Elevated temperature and excessive diaphoresis

b.

Loss of sensation and pallor near the surgical site

c.

Swelling, pain, and tension of the affected limb

d.

Increased pulse and warmth below the surgical site

ANS: C

Compartment syndrome occurs when tissue pressure within a confined space becomes elevated and blood flow is restricted. This causes increased swelling, tenderness, and tension in the affected limb.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

25. The nurse is caring for a client who develops compartment syndrome after an embolectomy for peripheral arterial disease. What is the nurses best action?

a.

Perform passive range-of-motion exercise to improve distal blood flow.

b.

Prepare the client for return to the operative suite for surgical correction.

c.

Medicate the client for pain and place the client in a knee-chest position.

d.

Loosen the dressing and elevate the extremity to the level of the heart.

ANS: D

When a client develops compartment syndrome, the nurse should remove or loosen the dressing and elevate the extremity to the level of the heart. In addition, the nurse must notify the health care provider immediately. Passive range of motion and the knee-chest position are not indicated. Preparing the client for return to the operating room is not indicated at this time. The priority is to relieve pressure by loosening the dressing and positioning the extremity at the level of the heart.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

26. The new graduate nurse is assessing a client with an unrepaired abdominal aortic aneurysm. What assessment technique requires further education by the supervising nurse?

a.

Measurement of abdominal girth

b.

Observation of abdominal wall movement

c.

Auscultation of any area of the abdomen

d.

Palpation of the abdominal midline area

ANS: D

Palpation on or near an aneurysm may cause pain and potential rupture. Observation, auscultation, and measurement are appropriate assessments.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Assessment)

27. A client with a diagnosed abdominal aortic aneurysm (AAA) develops lower back pain radiating to the groin. What is the nurses interpretation of this information?

a.

The aneurysm clotted and is obstructing blood flow.

b.

The aneurysm is expanding and is preparing to rupture.

c.

The client feels the inflammation of the aneurysm.

d.

This is a normal sensation associated with an AAA.

ANS: B

When an aneurysm is expanding or is preparing to rupture, the client may experience severe, sudden back or lower abdominal pain that can radiate to the groin, buttocks, or legs. The other explanations are not related to potential or actual rupture of the aneurysm.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

28. The nurse is preparing a client with an aortic aneurysm for surgery. The nurse notes that the clients systolic blood pressure has increased by 30 mm Hg compared with the reading 1 hour ago. What is the nurses best action?

a.

Measure abdominal girth.

b.

Auscultate the abdomen.

c.

Increase the IV infusion rate.

d.

Reassess the blood pressure.

ANS: A

A sudden increase in blood pressure or hypertension can cause enlargement or rupture of the aneurysm, which would be correlated with an increase in abdominal girth. The other options are not indicated.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems)

MSC: Integrated Process: Nursing Process (Implementation)

29. A nurse is recovering a client who has undergone surgical repair of an abdominal aortic aneurysm (AAA). The client develops coolness of the extremities and reports a bloated feeling in the abdomen. What is the nurses best action?

a.

Measure the abdominal girth and check pulses.

b.

Raise the head of the bed to 90 degrees.

c.

Assess cardiac output and blood pressure.

d.

Auscultate and then palpate the abdomen.

ANS: A

Graft occlusion or rupture is a postoperative complication following AAA repair. The nurse should monitor the client for increasing abdominal girth, cool or cold extremities, white or blue color in the flanks, and severe pain. Elevating the head of the bed would place too much pressure on the surgical site. The other two options are not warranted.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Nursing Process (Implementation)

30. The nurse is providing discharge education to a client after repair of an abdominal aortic aneurysm (AAA). What priority instruction does the nurse include?

a.

No restrictions on driving your car are necessary.

b.

Avoid sleeping on your left side for 6 weeks.

c.

Avoid lifting heavy objects for about 3 months.

d.

You will have a distended abdomen for 2 weeks.

ANS: C

Clients who have undergone AAA repair must refrain from placing stress on the graft. They should avoid lifting or pulling heavy objects, and activities such as vacuuming, raking leaves, and playing golf. Clients must be cleared by their surgeon for driving. The other two options are not valid instructions.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Teaching/Learning

31. The nurse is caring for a client with Buergers disease. What client education does the nurse provide to minimize disease progression?

a.

Keep environmental temperatures warm.

b.

Avoid highly stressful activities.

c.

Use a heating pad on your extremities.

d.

Abstain from all forms of tobacco.

ANS: D

The greatest risk factor for the development and progression of Buergers disease is cigarette smoking. To prevent the progression of Buergers disease, complete abstinence from tobacco in all forms is essential. The vasoconstrictive effects of each cigarette may last up to 1 hour after the cigarette is smoked. Teach the client to avoid extreme cold or prolonged exposure to cold to prevent vasoconstriction. Keeping the environment warm will minimize vasoconstriction but has no direct effect on disease progression. Heating pads should be avoided because injury can occur secondary to decreased sensation in the lower extremities.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Alterations in Body Systems) MSC: Integrated Process: Teaching/Learning

32. The nurse is assessing the extremities of a client with Buergers disease. What clinical manifestation does the nurse correlate with this disease?

a.

Reddened, with diminished distal pulses

b.

Cold and pale, with proximal bounding pulses

c.

Cyanotic, with decreased deep tendon reflexes

d.

Brownish discoloration, with pitting edema

ANS: A

Clients with Buergers disease manifest with reddened or cyanotic extremities in the dependent position and diminished distal pulses caused by occlusions in the smaller vessels. Clients also may have ulcerations or gangrene of the digits secondary to impaired circulation. Pulses are diminished, not bounding. Reflex activity is not usually affected by this disorder.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 797

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

33. The nurse is providing disease management education to a client with Raynauds disease. What intervention does the nurse suggest to prevent complications of this disease?

a.

Take vasoconstrictive agents when you have symptoms.

b.

Wear warm clothing when exposed to cool temperatures.

c.

Avoid placing alcohol-based lotion on affected extremities.

d.

Check the strength of pulses in your arms and legs daily.

ANS: B

Education is important for helping the client avoid complications. The client is instructed to wear warm clothing, such as socks and gloves, when exposed to cool temperatures to decrease vasoconstriction. The client may be prescribed vasodilators to prevent vasoconstriction.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Surgical Procedures and Health Alterations)

MSC: Integrated Process: Teaching/Learning

34. The nurse is caring for a client who is receiving heparin therapy for a venous thromboembolism (VTE). The clients activated partial thromboplastin time (aPTT) before heparin therapy was 30 seconds. Which aPTT result indicates that anticoagulation is adequate at this time?

a.

15 seconds

b.

30 seconds

c.

60 seconds

d.

150 seconds

ANS: C

Therapeutic aPTT values for clients receiving heparin should range from 1.5 to 2.5 times the control value.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 800

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests) MSC: Integrated Process: Nursing Process (Evaluation)

35. The health care provider has prescribed a client sodium warfarin (Coumadin) while he is still receiving intravenous heparin. Which is the nurses best action?

a.

Administer both heparin and warfarin as prescribed.

b.

Turn off the heparin before administering the warfarin.

c.

Clarify the warfarin order with the nursing supervisor.

d.

Hold the warfarin dose until the heparin is discontinued.

ANS: A

Although both heparin and warfarin are anticoagulants, they have different mechanisms of action and onsets of action. Because warfarin has such a slow onset, it must be started while the client is still receiving heparin. Once the warfarin is therapeutic, as evidenced by the international normalized ratio (INR), the clients heparin can be safely discontinued. Effects of heparin will be cleared from the clients bloodstream within a few hours.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesExpected Actions/Outcomes)

MSC: Integrated Process: Nursing Process (Implementation)

36. The nurse is discharging home a client at risk for venous thromboembolism (VTE) on low-molecular-weight heparin. What instruction does the nurse provide to this client?

a.

You must have your aPTT checked every 2 weeks.

b.

Massage the injection site after the heparin is injected.

c.

Notify your health care provider if your stools appear tarry.

d.

An IV catheter will be placed to administer your heparin.

ANS: C

As with any anticoagulation, low-molecular-weight heparin incurs risk of bleeding. Clients should be taught to report to their health care provider the presence of tarry stools, bleeding gums, hematuria, ecchymosis, or petechiae. Low-molecular-weight heparin does not affect activated partial thromboplastin time (aPTT), as does intravenous heparin. This type of heparin is administered subcutaneously to deliver a slow sustained response. Massaging the site would hasten absorption and decrease effects.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Teaching/Learning

37. The nurse is providing health education to a client with chronic venous stasis ulcers. What priority instruction does the nurse include?

a.

Apply antiembolism stockings before getting out of bed in the morning.

b.

Clean venous ulcers with Betadine before applying a dressing.

c.

Take 1 low-dose aspirin (81 mg) daily to prevent inflammation.

d.

Remove and reapply a new DuoDerm dressing to your ulcers each day.

ANS: A

Support hose or antiembolism stockings should be applied just before getting out of bed in the morning and should be removed before going to bed at night. Clients are advised that they will probably need to wear these stockings indefinitely. Betadine is not indicated and may cause irritation. Chronic venous ulcers are not caused by an inflammatory process, so daily aspirin is not indicated. Hydrocolloid (DuoDerm) dressings are left in place for a minimum of 3 to 5 days for best effect.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Teaching/Learning

38. The nurse is assessing for skin changes in an African-American client admitted with peripheral arterial disease. What does the nurse monitor for?

a.

Excess hair growth

b.

Pitting edema in the feet

c.

Cyanosis of the nail beds

d.

Loss of toenails

ANS: C

Because only severe cyanosis is evident in the skin of dark-skinned clients, cyanosis can be detected by assessing the skin and nail beds for a dull lifeless color. The soles of the feet and the toenails are less pigmented, which can enable detection of cyanosis or duskiness in the lower extremities. Loss of hair on the lower extremities is noted with peripheral artery disease. Pitting edema is associated with venous disease. Toenail beds are cyanotic, but loss of nails is not associated.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 786

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Assessment)

39. The nurse assesses a clients legs. Which assessment finding indicates arterial insufficiency?

a.

Ankle discoloration and pitting edema

b.

Dependent mottling and absence of hair

c.

Pain with activity but not while resting

d.

Full veins present in dependent extremity

ANS: B

Dependent mottling and absence of hair is an indication of arterial insufficiency. Pain may be present with activity and at rest. Edema and ankle discoloration would be indicative of venous insufficiency.

DIF: Cognitive Level: Knowledge/Remembering REF: p. 786

TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationPathophysiology)

MSC: Integrated Process: Nursing Process (Analysis)

MULTIPLE RESPONSE

1. The nurse is reviewing a clients laboratory results. The nurse correlates elevations in which values as risk factors for atherosclerosis? (Select all that apply.)

a.

Total cholesterol, 280 mg/dL

b.

High-density cholesterol, 50 mg/dL

c.

Triglycerides, 200 mg/dL

d.

Serum albumin, 4 g/dL

e.

Low-density cholesterol, 160 mg/dL

ANS: A, C, E

A lipid panel is often used to screen for cardiovascular risk. Total cholesterol, triglycerides, and low-density cholesterol levels are all high, indicating higher risk for cardiovascular disease. High-density cholesterol is within the normal range for both males and females. Serum albumin is not assessed for atherosclerosis.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests) MSC: Integrated Process: Nursing Process (Assessment)

2. An older adult client is prescribed furosemide (Lasix) for control of hypertension. What client education does the nurse provide? (Select all that apply.)

a.

Confusion can occur when taking this medication.

b.

Drink at least 3 liters of water every day.

c.

Arise slowly from a chair or from your bed.

d.

Persistent coughing is a side effect of this drug.

e.

You should eat foods high in potassium.

ANS: A, C, E

Diuretics such as furosemide and hydrochlorothiazide promote loss of potassium while preventing sodium and water reabsorption. Therefore, the client should incorporate foods high in potassium into the diet and may even require potassium supplementation. The medication should not affect the pulse rate, and swelling in the feet should decrease with this therapy. The client would have no reason to develop a cough while on the medication.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 780

TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Side Effects/Interactions)

MSC: Integrated Process: Nursing Process (Implementation)

3. The nurse is caring for a client who is experiencing excessive bleeding after receiving unfractionated heparin. What orders does the nurse anticipate from the health care provider? (Select all that apply.)

a.

Laboratory draw for activated partial thromboplastin time (aPTT)

b.

Administer vitamin K

c.

Laboratory draw for prothrombin time (PT)/international normalized ratio (INR)

d.

Administer protamine sulfate

e.

Administer enoxaparin (Lovenox)

ANS: A, D

Protamine sulfate is the antidote for heparin-induced bleeding. Vitamin K is the antidote for warfarin. Warfarin (Coumadin) would increase bleeding. Enoxaparin is another name for heparin.

DIF: Cognitive Level: Application/Applying or higher REF: N/A

TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialPotential for Complications from Diagnostic Tests/Treatments/Procedures)

MSC: Integrated Process: Nursing Process (Implementation)

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