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Chapter 33: Concepts of Care for Patients With Vascular Problems
Ignatavicius: Medical-Surgicalabirb.com/test
Nursing, 10th Edition
MULTIPLE CHOICE
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1. A nurse is assessing the peripheral vascular system of an older adult. What action by the nurse
would cause the supervising nurse to intervene?
a. Assessing blood pressure in both upper extremities
b. Auscultating the carotid arteries for any bruits
c. Classifying capillary filling of 4 seconds as normal
d. Palpating both carotid arteries at the same time
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ANS: D
The nurse would not compress both carotid arteries at the same time to avoid brain ischemia.
Blood pressure would be taken and compared in both arms. Prolonged capillary filling 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 would be auscultated.
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DIF:
TOP:
KEY:
MSC:
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Remembering
Integrated Process: Communication and Documentation
Vascular system, Nursing assessment
Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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2. The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel.
What meal selection indicates that 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
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ANS: B
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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.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Nutrition, Self-care
MSC: Client Needs Category: Health Promotion and Maintenance
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3. A nurse is working with a client who takes clopidogrel. The client’s recent laboratory results
include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action
by the nurse is best?
a. Ask if the client eats grapefruit.
b. Assess the client for dehydration.
c. Facilitate admission to the hospital.
d. Obtain a random urinalysis.
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ANS: A
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There is a drug–food interaction between clopidogrel and grapefruit that can lead to acute
kidney failure. This client has elevated renal laboratory results, indicating some degree of
kidney involvement. The nurse would 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.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Medication-food interactions, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
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4. A client has been diagnosed with hypertension but does not take the antihypertensive
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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.”
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ANS: B
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Most people with hypertension are asymptomatic, although a small percentage do have
symptoms such as headache. The nurse would explain this to the client. Asking about paying
for medications utilizes closed-ended questioning and is not therapeutic. Threatening the
client with possible complications will not increase compliance.
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DIF:
TOP:
KEY:
MSC:
Understanding
Integrated Process: Communication and Documentation
Hypertension, Medication adherence
Client Needs Category: Physiological Integrity: Physiological Adaptation
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5. A client 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.”
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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.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Hypertension, Pathophysiology
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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6. A nurse is interested in providing community education and screening on hypertension. In
order to reach a priority population, to what target audience would the nurse provide this
service?
a. African-American churches
b. Asian-American groceries
c. High school sports camps
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d. Women’s health clinics
ANS: A
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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.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Analysis
KEY: Hypertension, Primary prevention
MSC: Client Needs Category: Health Promotion and Maintenance
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7. 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 client’s 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 client’s obligations.
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ANS: B
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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 would 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 client’s feelings of control.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Hypertension, Psychosocial response
MSC: Client Needs Category: Psychosocial Integrity
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8. The nurse is caring for four hypertensive clients. Which drug–laboratory value combination
would the nurse report immediately to the health care provider?
a. Furosemide/potassium: 2.1 mEq/L
b. Hydrochlorothiazide/potassium: 4.2 mEq/L
c. Spironolactone/potassium: 5.1 mEq/L
d. Torsemide/sodium: 142 mEq/L
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ANS: A
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Furosemide is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is
quite low and would 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.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Analysis
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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9. A nurse is assessing a client with peripheral artery disease (PAD). The client states that
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?”
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c. “Have you ever considered swimming instead of walking?”
d. “How much pain medication do you take each day?”
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ANS: A
As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on
activity to be pain free indicates that the client’s disease is worsening. The other questions are
useful, but not as important.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Peripheral artery disease, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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10. 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. “I’m glad I get energy assistance so my house isn’t 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.”
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ANS: D
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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 would 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.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Analysis
KEY: Peripheral vascular disease, Home safety
MSC: Client Needs Category: Health Promotion and Maintenance
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11. A client is taking warfarin and asks the nurse if taking St. John’s wort is acceptable. What
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response by the nurse is best?
a. “No, it may interfere with the warfarin.”
b. “There isn’t any information about that.”
c. “Why would you want to take that?”
d. “Yes, it is a good supplement for you.”
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ANS: A
Many foods and drugs interfere with warfarin, St. John’s wort being one of them. The nurse
would advise the client against taking it. The other answers are not accurate.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Anticoagulants, Medication-food interactions
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
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12. A nurse is teaching a female client about alcohol intake and how it affects hypertension. The
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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.”
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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.”
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ANS: A
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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 woman’s size does not matter.
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DIF: Understanding
TOP: Integrated Process: Teaching/Learning
KEY: Hypertension, Lifestyle choices
MSC: Client Needs Category: Health Promotion and Maintenance
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13. A nurse is caring for four clients. Which one would the nurse see first?
a. Client who needs a beta blocker, and has a blood pressure of 98/58 mm Hg.
b. Client who had a first dose of captopril 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.
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ANS: B
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Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially
after the first dose. The nurse would 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 would 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 to 100 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.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Analysis
KEY: Hypertension, Angiotensin-converting enzyme (ACE) inhibitors
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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14. A client had a percutaneous angioplasty for renovascular hypertension 3 months ago. What
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assessment finding by the nurse indicates that an important outcome for this client has been
met?
a. Client is able to decrease blood pressure medications.
b. Insertion site has healed without redness or tenderness.
c. Most recent lab data show BUN: 19 mg/dL and creatinine 1.1 mg/dL.
d. Verbalizes understanding of postprocedure lifestyle changes.
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ANS: A
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Hypertension can be caused by renovascular disease. Opening up a constricted renal artery
can lead to decreased blood pressure, manifested by the need for less blood pressure
medication. The other findings are normal and desired, but not specifically related to
hypertension caused by renal disease.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Hypertension, Perfusion
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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15. A client is 4 hours postoperative after a femoral-popliteal bypass. The client reports throbbing
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leg pain on the affected side, rated as 7/10. What action by the nurse is most important?
a. Administer pain medication as ordered.
b. Assess distal pulses and skin color.
c. Document the findings in the client’s chart.
d. Notify the surgeon immediately.
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ANS: B
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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 would assess for other signs of perfusion, such as distal pulses
and skin color/temperature. Administering pain medication is done once the nurse determines
that the client’s perfusion status is normal. Documentation needs to be thorough. Notifying the
surgeon is not necessary.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Peripheral vascular disease, Nursing process assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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16. A client had a femoral-popliteal 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 client’s temperature every 4 hours
c. Clean technique when changing dressings
d. Monitoring the client’s daily white blood cell count
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ANS: A
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Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes
would be done with sterile technique. Assessing vital signs and white blood cell count will not
prevent infection.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Infection control, Hand hygiene
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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17. A client is receiving an infusion of alteplase for an intra-arterial clot. The client begins to
mumble and is disoriented. What action by the nurse is most important?
Assess the client’s neurologic status.
Notify the Rapid Response Team.
Prepare to administer vitamin K.
Turn down the infusion rate.
a.
b.
c.
d.
ANS: B
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Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic
signs may indicate that the client is having a hemorrhagic stroke. The nurse does need to
complete a thorough neurologic examination, but would first call the Rapid Response Team
based on the client’s manifestations. 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.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Critical rescue, Fibrinolytic agents
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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18. A new nurse is caring for a client with an abdominal aneurysm. What action by the new nurse
requires the nurse’s mentor 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.
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ANS: D
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Abdominal aneurysms should never be palpated as this increases the risk of rupture. The nurse
mentoring the new nurse would intervene when the new nurse attempts to do this. The other
actions are appropriate.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Aneurysms, Abdominal assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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19. A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment
indicates that an important outcome has been met?
a. Ambulates with assistance
b. Oxygen saturation of 98%
c. Pain of 2/10 after medication
d. Verbalizing risk factors
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ANS: B
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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 as important.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Assessment
KEY: Pulmonary embolism, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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20. A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to
the assistive personnel (AP)?
a. Ambulate the client.
b. Apply a warm moist pack.
c. Massage the client’s leg.
d. Provide an ice pack.
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ANS: B
Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure.
Massaging the client’s legs is contraindicated to prevent complications such as pulmonary
embolism. Ice packs are not recommended for DVT.
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DIF:
TOP:
KEY:
MSC:
Understanding
Integrated Process: Communication and Documentation
Thromboembolic event, Comfort measures
Client Needs Category: Physiological Integrity: Basic Care and Comfort
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21. 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 lb (9.09 Kg) since the last visit. What action by the nurse is
best?
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a.
b.
c.
d.
Ask if the weight loss was intended.
Encourage a high-protein, high-fiber diet.
Measure for new compression stockings.
Review a 3-day food recall diary.
ANS: C
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Compression stockings must fit correctly in order to work. After losing a significant amount
of weight, the client would be remeasured and new stockings ordered if needed. The other
options are appropriate, but not the most important.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Thromboembolic event, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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22. 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.
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ANS: B
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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.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Hypertension, Primary prevention
MSC: Client Needs Category: Health Promotion and Maintenance
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23. A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin.
The client is adamant about refusing the drug because “it’s dangerous.” What action by the
nurse is best?
a. Assess the reason behind the client’s fear.
b. Remind the client about laboratory monitoring.
c. Tell the client that drugs are safer today than before.
d. Warn the client about consequences of noncompliance.
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ANS: A
The first step is to assess the reason behind the client’s fear, which may be related to the
experience of someone the client knows who took warfarin or misinformation. 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.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Psychosocial response, Therapeutic communication
MSC: Client Needs Category: Psychosocial Integrity
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24. A client with a history of heart failure and hypertension is in the clinic for a follow-up visit.
The client is on lisinopril and warfarin. The client reports new-onset cough. What action by
the nurse is most appropriate?
a. Assess the client’s 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 lisinopril.
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ANS: A
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This client could be having an exacerbation of heart failure or experiencing a side effect of
lisinopril (and other angiotensin-converting enzyme inhibitors). The nurse would assess the
client’s 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 would 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.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Angiotensin-converting enzyme (ACE) inhibitors, Adverse effects
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
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25. 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 care nurse.
b. Give pain medication prior to dressing changes.
c. Maintain sterile technique for dressing changes.
d. Prepare the client for eventual amputation.
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ANS: A
A nonhealing wound needs the expertise of the wound care 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.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Peripheral arterial disease, Wound care
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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26. 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 it’s 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. “It’s going to be really hard but I will stop smoking.”
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ANS: A
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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.
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DIF: Evaluating
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Peripheral arterial disease, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
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27. The nurse is assessing a client on admission to the hospital. The client’s leg appears as shown
below:
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What action by the nurse is best?
a. Assess the client’s ankle-brachial index.
b. Elevate the client’s leg above the heart.
c. Obtain an ice pack to provide comfort.
d. Prepare to teach about heparin sodium.
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ANS: A
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This client has dependent rubor, a classic finding in peripheral arterial disease. The nurse
would measure the client’s 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.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Peripheral vascular disease, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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MULTIPLE RESPONSE
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1. What nonpharmacologic comfort measures would 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
f. Encouraging participation in high impact aerobic activity
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ANS: B, C, D
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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. High impact aerobics is not encouraged and is not a comfort
measure.
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DIF:
TOP:
KEY:
MSC:
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Understanding
Integrated Process: Nursing Process: Implementation
Peripheral vascular disease, Nonpharmacologic comfort measures
Client Needs Category: Physiological Integrity: Basic Care and Comfort
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2. A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the
nurse delegate to the assistive personnel (AP)? (Select all that apply.)
a. Administering preoperative medication
b. Ensuring that the consent is signed
c. Marking pulses with a pen
d. Raising the side rails on the bed
e. Recording baseline vital signs
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ANS: D, E
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The AP can raise the side rails of the bed for client safety and take and record the vital signs.
Administering medications, ensuring that a consent is on the chart, and marking the pulses for
later comparison would be done by the registered nurse. This is also often done by the
postanesthesia care nurse and is part of the hand-off report.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Delegation, Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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3. A client has been bedridden for several days after major abdominal surgery. What action does
the nurse delegate to the assistive personnel (AP) 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.
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ANS: A, B, D
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The AP can apply compression stockings, assist with ambulation, and offer fluids frequently
to help prevent DVT. The AP can also encourage the client to do pulmonary exercises, but
these do not decrease the risk of DVT. Teaching is a nursing function.
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DIF: Applying
TOP: Integrated Process: Communication and Documentation
KEY: Deep vein thrombosis, Delegation
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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4. A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include
in the client’s 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.
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d. Use an IV pump for the infusion.
e. Weigh the client daily on the same scale.
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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 2.5 times normal in order to demonstrate that the heparin is therapeutic. Weighing the
client is not related.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Intervention
KEY: Anticoagulants, Client safety
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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5. A client is being discharged on warfarin therapy. What discharge instruction 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
f. Wearing a Medic Alert bracelet
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ANS: A, C, D, E
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Best practices state that clients being discharged on warfarin need instruction on follow-up
monitoring, dietary restrictions, drug–drug interactions, using a Medic Alert bracelet or
necklace, and reason for compliance. Driving is typically not restricted.
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DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Anticoagulants, Health teaching
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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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. “I’ll 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.”
f. “I will inspect my feet daily.”
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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;
cutting the nails straight across; and inspecting the feet daily are all important measures.
Abrasive material such as pumice stones would not be used. Cheap flip-flops may not fit well
and won’t offer much protection against injury.
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DIF: Analyzing
TOP: Integrated Process: Nursing Process: Evaluation
KEY: Peripheral vascular disease, Health teaching
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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7. A nurse is caring for a client with a nonhealing arterial ulcer. The primary health care provider
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has informed the client about possibly needing to amputate the client’s 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.
f. Arrange for an amputee to come visit the client.
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ANS: A, B, C
When a client is upset, the nurse would 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 client’s
feelings. It is too early to send an amputee to visit the client as the decision to amputate has
not yet been made.
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DIF: Applying
TOP: Integrated Process: Caring
KEY: Psychosocial response, Therapeutic communication
MSC: Client Needs Category: Psychosocial Integrity
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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
f. Hyperlipidemia
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ANS: A, D, E, F
Atherosclerosis, hypertension, hyperlipidemia, hyperlipidemia, and smoking are the most
commonly related factors. Down syndrome and heartburn have no relation to aneurysm
formation.
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DIF: Remembering
TOP: Integrated Process: Teaching/Learning
KEY: Peripheral vascular disorders, Pathophysiology
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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9. A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal
pain. The nurse assesses the client’s 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.
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ANS: B, D, E
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This client may have a ruptured/rupturing aneurysm. The nurse would notify the Rapid
Response team and perform frequent client assessments. Giving pain medication will lower
the client’s blood pressure even further. The nurse cannot have the client sign a consent until
the surgeon has explained the procedure.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Implementation
KEY: Aneurysm, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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10. A client presents to the emergency department with a thoracic aortic aneurysm. Which
findings are most consistent with this condition? (Select all that apply.)
a. Abdominal tenderness
b. Difficulty swallowing
c. Changes in bowel habits
d. Shortness of breath
e. Hoarseness
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ANS: B, E
Signs of a thoracic aortic aneurysm include shortness of breath, hoarseness, and difficulty
swallowing. Pain is often rated as a 10 on a 10-point scale. Bowel habits are not related.
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DIF: Applying
TOP: Integrated Process: Nursing Process: Assessment
KEY: Aortic aneurysm, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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11. The nurse is reviewing risk factors in a client who has atherosclerosis. Which findings are
most concerning? (Select all that apply.)
a. Elevated low-density lipoprotein (LDL-C)
b. Decreased levels of high-density lipoprotein cholesterol (HDL-C)
c. Asian ethnicity
d. History of smoking
e. Blood pressure: 142/92 mm Hg on one occasion
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ANS: A, B, D
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Elevated levels of lipids (fats) such as low-density lipoprotein cholesterol (LDL-C) and
decreased levels of high-density lipoprotein cholesterol can cause chemical damage to blood
vessel walls. Smoking can cause endothelial damage in addition to increasing a client’s
carbon monoxide levels. African American and Hispanic ethnicities carry an increased risk for
atherosclerosis. Hypertension does increase atherosclerosis risk, but an elevated reading on
one occasion is not classified as hypertension.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Assessment
KEY: Atherosclerosis, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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