PERIPHERAL VASCULAR DISORDERS
https://www.rnpedia.com/practice-exams/medical-and-surgical-nursingexams/msn-exam-for-peripheral-vascular-diseases/
https://quizlet.com/73334214/nclex-s-peripheral-vascular-disease-flash-cards/
UDAN
1. One goal in caring for a client with arterial occlusive disease is to promote
vasodilation in the affected extremity. To achieve this goal, the nurse encourages the
client to:
a. Avoid eating low-fat-foods.
b. Elevate the legs above the heart.
c. Stop smoking.
d. Begin a jogging program.
2. The client with Buerger's disease experiences which of the following signs and
symptoms?
a. Thickening of the intima and media of the artery.
b. Inflammation and fibrosis of arteries, veins and nerves.
c. Vasospasm lasting several minutes.
d. Pain, pallor and pulselessness.
3. Stress can produce vasospasm in clients with Raynaud's disease. The client states
she is worried about making the necessary behavioral changes to control the
vasospastic episodes. Which of the following diagnoses is appropriate?
a. Activity intolerance related to Raynaud's disease.
b. Anxiety related to change in health status.
c. Disturbed body image related to illness treatment.
d. Impaired social interaction related to self-concept disturbance.
4. Which of the following increases the risk of having a large abdominal aortic aneurysm
rupture?
a. Anemia.
b. Dehydration.
c. High blood pressure.
d. Hyperglycemia.
5. A client diagnosed with thrombophlebitis suddenly complains of chest pain and
shortness of breath and is restless. The nurse should assess the client for:
a. Myocardial infarction.
b. Pneumonia.
c. Pulmonary embolism.
d. Pulmonary edema
6. A 34-year-old male is diagnosed to have Buerger's disease. The nurse notes
intermittent claudication in the arch of the foot and thrombophlebitis of the lower leg.
Which of the following factors is associated with Buerger's disease?
a. Familial pattern toward peripheral vascular disease.
b. Smoking history
c. History of recent insect bites.
d. Recent exposure to allergens.
7. Which of the following manifestations would least likely be experienced by the client
with abdominal, aortic aneurysm (AAA)?
a. Pulsatile abdominal mass.
b. Bruit on auscultation of the mass.
c. Hyperactive bowel sounds.
d. Sensation of "heart beating in the abdomen."
8. Lasix (Furosemide) is contraindicated if the client has hypersensitivity to:
a. Sulfonamides
b. Penicillin
c. Aminoglycosides
d. Quinolones
9. A client with hypertension is on ACE inhibitor (Monopril). Which of the following
diuretics is contraindicated?
a. Lasix
b. Bumex
c. Aldactone
d. HydroDiuril
10. The following are clinical manifestations of arterial insufficiency. Select all that apply.
a. Leg pain relieved by rest.
b. Cold skin in the lower extremities.
c. Reddish skin in the leg.
d. Diminished pulse in the leg.
e. Edema improved with elevation.
f. Loss of hair in the legs.
g. Presence of gangrene
BRUNNER
1. The nurse is taking a health history of a new patient. The patient reports experiencing
pain in his left lower leg and foot when walking. This pain is relieved with rest. The
nurse notes that the left lower leg is slightly edematous and is hairless. When planning
this patient subsequent care, the nurse should most likely address what health
problem?
A) Coronary artery disease (CAD)
B) Intermittent claudication
C) Arterial embolus
D) Raynaud’s disease
Feedback: A muscular, cramp-type pain in the extremities consistently reproduced with
the same degree of exercise or activity and relieved by rest is experienced by patients
with peripheral arterial insufficiency. Referred to as intermittent claudication, this pain is
caused by the inability of the arterial system to provide adequate blood flow to the
tissues in the face of increased demands for nutrients and oxygen during exercise. The
nurse would not suspect the patient has CAD, arterial embolus, or Raynauds disease;
none of these health problems produce this cluster of signs and symptoms.
2. While assessing a patient the nurse notes that the patient’s ankle-brachial index (ABI)
of the right leg is 0.40. How should the nurse best respond to this assessment finding?
A) Assess the patients use of over-the-counter dietary supplements.
B) Implement interventions relevant to arterial narrowing
C) Encourage the patient to increase intake of foods high in vitamin K
D) Adjust the patient’s activity level to accommodate decreased coronary output.
Feedback: ABI is used to assess the degree of stenosis of peripheral arteries, An ABI of
less than 1.0 indicates possible claudication of the peripheral arteries. It does not
indicate inadequate coronary output. There is no direct indication for changes in vitamin
K intake and OTC medications are not likely causative.
3. The nurse is providing care for a patient who has just been diagnosed with peripheral
arterial occlusive disease (PAD). What assessment finding is most consistent with this
diagnosis?
A) Numbness and tingling in the distal extremities
B) Unequal peripheral pulses between extremities
C) Visible clubbing of the fingers and toes
D) Reddened extremities with muscle atrophy
Feedback: PAD assessment may manifest as unequal pulses between extremities, with
the affected leg cooler and paler than the unaffected leg. Intermittent claudication is far
more common than sensations of numbness. and tingling. Clubbing and muscle atrophy
are not associated with PAD.
4. The nurse is admitting a 32-year-old woman to the presurgical unit. The nurse learns
during the admission assessment that the patient takes oral contraceptives.
Consequently, the nurses postoperative plan of care should include what intervention?
A) Early ambulation and leg exercises
B) Cessation of the oral contraceptives until 3 weeks postoperative
Doppler ultrasound of peripheral circulation twice daily
D) Dependent positioning of the patients extremities when at rest
Feedback: Oral contraceptive use increases blood coagulability, with bed rest, the
patient may be at increased risk of developing deep vein thrombosis. Leg exercises and
early ambulation are among the interventions. that address this risk. Assessment of
peripheral circulation is important, but Doppler ultrasound may not be necessary to
obtain these data. Dependent positioning increases the risk of venous
thromboembolism. (VTE). Contraceptives are not normally discontinued to address the
risk of VTE in the short term.
5. A nurse is creating an education plan for a patient with venous insufficiency. What
measure should the nurse include in the plan?
A) Avoiding tight-fitting socks.
B) By Limit activity whenever possible.
C) Sleep with legs in a dependent position.
D) Avoid the use of pressure stockings
Feedback: Measures taken to prevent complications include avoiding tight-fitting socks
and panty girdles; maintaining activities, such as walking, sleeping with legs elevated,
and using pressure stockings. Not included in the teaching plan for venous insufficiency
would be reducing activity, sleeping with legs dependent, and avoiding pressure
stockings. Each of these actions exacerbates venous insufficiency.
6. The nurse is caring for a patient with a large venous leg ulcer. What intervention
should the nurse implement to promote healing and prevent infection?
A) Provide a high-caloric, high-protein diet.
B) Apply a clean occlusive dressing once daily and whenever soiled.
C) Irrigate the wound with hydrogen peroxide once daily.
D) Apply an antibiotic ointment on the surrounding skin with each dressing change.
Feedback: Wound healing is highly dependent on adequate nutrition. The diet should be
sufficiently high in calories and protein. Antibiotic ointments are not normally used on
the skin surrounding a leg ulcer and occlusive dressings can exacerbate impaired blood
flow. Hydrogen peroxide is not normally used because it can damage granulation tissue.
7. The nurse is caring for a patient who returned from the tropics a few weeks ago and
who sought care with signs and symptoms of lymphedema. The nurses plan of care
should prioritize what nursing diagnosis?
A) Risk for infection related to lymphedema
B) Disturbed body image related to lymphedema
C) Ineffective health maintenance related to lymphedema
D) Risk for deficient fluid volume related to lymphedema
Feedback: Lymphodema, which is caused by accumulation of lymph in the tissues,
constitutes a significant risk for infection. The patients body image is likely to be
disturbed, and the nurse should address this, but infection is a more significant threat to
the patients physiological well-being. Lymphedema is unrelated to ineffective health
maintenance and deficient fluid volume is not a significant risk.
8. An occupational health nurse is providing an educational event and has been asked
by an administrative worker about the risk of varicose veins. What should the nurse
suggest as a proactive preventative measure for varicose veins?
A) Sit with crossed legs for a few minutes each hour to promote relaxation,
B) Walk for several minutes every hour to promote circulation.
C) Elevate the legs when tired.
D) Wear snug-fitting ankle socks to decrease edema.
Feedback: A proactive approach to preventing varicose veins would be to walk for
several minutes every hour to promote circulation. Sitting with crossed legs may
promote relaxation. on, but it is contraindicated for patients with, or at risk for, varicose
veins. Elevating the legs only helps blood passively return to the heart and does not
help maintain the competency of the valves in the veins. Wearing tight ankle socks is
contraindicated for patients with, or at risk for, varicose veins; socks that are below the
muscles of the calf do not promote venous return, the socks simply capture the blood
and promote venous stasis.
9. A patient comes to the walk-in clinic with complaints of pain in his foot following
stepping on a roofing nail 4 days ago. The patient has a visible red streak running up his
foot and ankle. What health problem should the nurse suspect?
A) Cellulitis
B) Local inflammation
C) Elephantiasis
D) Lymphangitis
Feedback: Lymphangitis is an acute inflammation of the lymphatic channels. It arises
most commonly from a focus of infection in an extremity. Usually, the infectious
organism is hemolytic streptococcus. The characteristic red streaks that extend up the
arm or the leg from an infected wound outline the course of the lymphatic vessels as
they drain. Cellulitis is caused by bacteria, which cause a generalized edema in the
subcutaneous tissues surrounding the affected area. Local inflammation would not
present with red streaks in the lymphatic channels. Elephantiasis is transmitted by
mosquitoes that carry parasitic worm larvae, the parasites obstruct the lymphatic
channels and results in gross enlargement of the limbs.
10. The triage nurse in the ED is assessing a patient who has presented with complaint
of pain and swelling in her right lower leg. The patients pain became much worse last
night and appeared along with fever, chills, and sweating. The patient states, I hit my
leg on the car door 4 or 5 days ago and it has been sore ever since. The patient has a
history of chronic venous insufficiency. What intervention should the nurse anticipate for
this patient?
A) Platelet transfusion to treat thrombocytopenia
B) Warfarin to treat arterial insufficiency
C) Antibiotics to treat cellulitis
D) Heparin IV to treat VTE
Feedhack: Collulitis is the most common infectious cause of limb swelling. The signs
and symptoms include acute onset of swelling, localized redness, and pain; it is
frequently associated with systemic signs of fever, chills, and sweating. The patient may
be able to identify a trauma that accounts for the source of infection. Thrombocytopenia
is a loss or decrease in platelets and increases a patients risk of bleeding, this problem
would not cause these symptoms. Arterial insufficiency would present with ongoing pain
related to activity. This patient does not have signs and symptoms of VTE
11. A nurse in a long-term care facility is caring for an 83-year-old woman who has a
history of HF and peripheral arterial disease (PAD). At present the patient is unable to
stand or ambulate. The nurse should implement measures to prevent what
complication?
A) Aoritis
B) Deep vein thrombosis
C) Thoracic aortic aneurysm
D) Raynauds disease
Feedback: Although the exact cause of venous thrombosis remains unclear, three
factors, known as Virchows triad, are believed to play a significant role in its
development: stasis of blood (venous stasis), vessel wall injury, and altered blood
coagulation. In this womans case, she has venous stasis from immobility, vessel wall
injury from PAD, and altered blood coagulation from HF. The cause of aoritis is
unknown. but it has no direct connection to HF. PAD, or mobility issues. The greatest
risk factors for thoracic aortic aneurysm are atherosclerosis and hypertension; there is
no direct connection to HF, PAD, or mobility issues. Raynauds disease is a disorder that
involves spasms of blood vessels and, again, no direct connection to HF. PAD, or
mobility issues.
12. A nurse is admitting a 45-year-old man to the medical unit who has a history of
PAD. While providing his health history, the patient reveals that he smokes about two
packs of cigarettes a day, has a history of alcohol abuse, and does not exercise. What
would be the priority health education for this patient?
A) The lack of exercise, which is the main cause of PAD.
B) The likelihood that heavy alcohol intake is a significant risk factor for PAD.
C) Cigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or
aggravate PAD
D) Alcohol suppresses the immune system, creates high glucose levels, and may cause
PAD.
Feedback: Tobacco is powerful vasoconstrictor; its use with PAD is highly detrimental,
and patients are strongly advised to stop using tobacco. Sedentary lifestyle is also a risk
factor, but smoking is likely a more significant risk factor that the nurse should address.
Alcohol use is less likely to cause PAD, although it carries numerous health risks.
13. A nurse has written a plan of care for a man diagnosed with peripheral arterial
insufficiency. One of the nursing diagnoses in the care plan is altered peripheral tissue
perfusion related to compromised circulation. What is the most appropriate intervention
for this diagnosis?
A) Elevate his legs and arms above his heart when resting.
B) Encourage the patient to engage in a moderate amount of exercise.
C) Encourage extended periods of sitting or standing.
D) Discourage walking in order to limit pain.
Feedback: The nursing diagnosis of altered peripheral tissue perfusion related to
compromised circulation requires interventions that focus on improving circulation.
Encouraging the patient to engage in a moderate amount of exercise serves to improve
circulation. Elevating his legs and arms above his heart when resting would be passive
and fails to promote circulation. Encouraging long periods of sitting or standing would
further compromise circulation. The nurse should encourage, not discourage, walking to
increase circulation and decrease pain.
14. The nurse is caring for a 72-year-old patient who is in cardiac rehabilitation following
heart surgery. The patient has been walking on a regular basis for about a week and
walks for 15 minutes 3 times a day. The patient states that he is having a cramp-like
pain in the legs every time he walks and that the pain gets better when I rest. The
patients care plan should address what problem?
A) Decreased mobility related to VTE
B) Acute pain related to intermittent claudication
C) Decreased mobility related to venous insufficiency
D) Acute pain related to vasculitis.
Feedback: Intermittent claudication presents as a muscular, cramp-type pain in the
extremities consistently. reproduced with the same degree of exercise or activity and
relieved by rest. Patients with peripheral arterial insufficiency often complain of
intermittent claudication due to a lack of oxygen to muscle tissue Venous insufficiency
presents as a disorder of venous blood reflux and does s not present with crump-type
pain with exercise. Vasculitis is an inflammation of the blood vessels and presents with
weakness, fever, and fatigue, but does not present with cramp-type pain with exercise.
The pain associated with VTE does not have this clinical presentation.
15. A nurse in the rehabilitation unit is caring for an older adult patient who is in cardiac
rehabilitation following an MI. The nurses plan of care calls for the patient to walk for 10
minutes 3 times a day. The patient questions the relationship between walking and
heart function. How should the nurse best reply"
A) The arteries in your legs constrict when you walk and allow the blood to move faster
and with more pressure on the tissue.
B) Walking increases your heart rate and blood pressure. Therefore your heart is under
less stress.
C) Walking helps your heart adjust to your new arteries and helps build your selfesteem.
D) When you walk, the muscles in your legs contract and pump the blood in your veins
hack toward your heart, which allows more blood to return to your heart.
Feedback: Veins, unlike arteries, are equipped with valves that allow blood to move
against the force of gravity. The legs have one-way bicuspid valves that prevent blood
from seeping backward as it moves forward by the muscles in our legs pressing on the
veins as we walk and increasing venous return. Leg arteries do constrict when walking,
which allows the blood to move faster and with more pressure on the tissue, but the
greater concern is increasing the flow of venous blood to the heart. Walking increases,
not decreases, the heart pumping ability, which increases heart rate and blood pressure
and the hearts ability to manage stress, Walking does help the heart adjust to new
arteries and may enhance self-esteem, but the patient had an Mithere are no new
arteries.
16. The nurse is caring for a patient who is admitted to the medical unit for the treatment
of a venous ulcer in the area of her lateral malleolus that has been unresponsive to
treatment. What is the nurse most likely to find during an assessment of this patients
wound?
A) Hemorrhage
B) Heavy exudate
C) Deep wound bed
D) Pale-colored wound bed
Feedback: Venous ulcerations in the area of the medial or lateral malleolus (gaiter area)
are typically large, superficial, and highly exudative. Venous hypertension causes
extravasation of blood, which discolors the area of the wound bed. Bleeding is not
normally present
17. The nurse is preparing to administer warfarin (Coumadin) to a client with deep vein
thrombophlebitis (DVT). Which laboratory value would most clearly indicate that the
patients warfarin is at therapeutic levels
A) Partial thromboplastin time (PTT) within normal reference range
B) Prothrombin time (PT) eight to ten times the control
C) International normalized ratio (INR) between 2 and 3.
D) Hematocrit of 32%
Feedback: The INR is most often used to determine if warfarin is at a therapeutic level;
an INR of 2 to 3 is considered therapeutic. Warfarin is also considered to be at
therapeutic levels when the clients PT is 1.5 to 2 times the control. Higher values
indicate increased risk of bleeding and hemorrhage, whereas lower values indicate
increased risk of blood clot formation. Heparin, not warfarin, prolongs PTT. Hematocrit
does not provide information on the effectiveness of warfarin; however, a falling
hematocrit in a client taking warfarin may be a sign of hemorrhage.
18. The clinic nurse is caring for a 57-year-old client who reports experiencing log pain
whenever she walks several blocks. The patient has type 1 diabetes and has smoked a
pack of cigarettes every day for the past 40 years. The physician diagnoses intermittent
claudication. The nurse should provide what instruction about long-term care to the
client?
A) Be sure to practice meticulous foot care.
B) Consider cutting down on your smoking.
C) Reduce your activity level to accommodate your limitations.
D) Try to make sure you eat enough protein.
Feedback: The patient with peripheral vascular disease or diabetes should receive
education or reinforcement about skin and foot care, Intermittent claudication and other
chronic peripheral vascular diseases reduce oxygenation to the feet, making them
susceptible to injury and poor healing, therefore, meticulous foot care is essential. The
patient should stop smoking not just cut down because nicotine is a vasoconstrictor.
Daily walking benefits the patient with intermittent claudication. Increased protein intake
will not alleviate the patients symptoms.
19. A patient who has undergone a femoral to popliteal bypass graft surgery returns to
the surgical unit. Which assessments should the nurse perform during the first
postoperative day?
A) Assess pulse of affected extremity every 15 minutes at first.
B) Palpate the affected leg for pain during every assessment.
C) Assess the patient for signs and symptoms of compartment syndrome every 2 hours.
D) Perform Doppler evaluation once daily.
Feedback: The primary objective in the postoperative period is to maintain adequate
circulation through the arterial repair. Pulses, Doppler assessment, color and
temperature, capillary refill, and sensory and motor function of the affected extremity are
checked and compared with those of the other extremity; these values are recorded
initially every 15 minutes and then at progressively longer intervals if the patients status
remains stable. Doppler evaluations should be performed every 2 hours. Pain is
regularly assessed, but palpation is not the preferred method of performing this
assessment. Compartment syndrome results from the placernent of a cast, not from
vascular surgery.
20. You are caring for a patient who is diagnosed with Raynauds phenomenon. The
nurse should plant interventions to address what nursing diagnosis"
A) Chronic pain
B) Ineffective tissue perfusion
C) Impaired skin integrity
D) Risk for injury
Feedback: Raynauds phenomenon is a form of intermittent arteriolar vasoconstriction
resulting in inadequate tissue perfusion. This results in coldness, pain, and pallor of the
fingertips or toes. Pain is typically intermittent and acute, not chronic, and skin integrity
is rarely at risk. In most cases, the patient is not at a high risk for injury.
21. A patient presents to the clinic complaining of the inability to grasp objects with her
right hand. The patients right arm is cool and has a difference in blood pressure of more
than 20 mm Hg compared with her left arm. The nurse should expect that the primary
care provider may diagnose the woman with what health problem?
A) Lymphedema
B) Raynauds phenomenon
C) Upper extremity arterial occlusive disease
D) Upper extremity VTE
Feedback: The patient with upper extremity arterial occlusive disease typically
complains of arm fatigue and pain with exercise (forearm claudication) and inability to
hold or grasp objects (e) g. combing hair, placing objects on shelves above the head)
and, occasionally, difficulty driving. Assessment findings include coolness and paller of
the affected extremity, decreased capillary refill, and a difference in arm blood
pressures of more than 20 mm Hg. These symptoms are not closely associated with
Raynauds or lymphedema. The upper extremities are rare sites for VTE
22. A nurse working in a long-term care facility is performing the admission assessment
of a newly admitted, 85-year-old resident. During inspection of the residents feet, the
nurse notes that she appears to have early evidence of gangrene on one of her great
toes. The nurse knows that gangrene in the elderly is often the first sign of what"
A) Chronic venous insufficiency
B) Raynauds phenomenon.
C) VTE
D) PAD
Feedback: In elderly people, symptoms of PAD may be more pronounced than in
younger people. In elderly patients who are inactive, gangrene may be the first sign of
disease. Venous insufficiency does not normally manifest with gangrene. Similarly, VTE
and Raynauds phenomenon do not cause the ischemia that underlies gangrene.
23. The prevention of VTE is an important part of the nursing care of high-risk patients.
When providing patient teaching for these high-risk patients, the nurse should advise
lifestyle changes, including which of the following? Select all that apply.
A) High-protein diet
B) Weight loss
C) Regular exercise
D) Smoking cessation
E Calcium and vitamin D supplementation
Feedback: Patients at risk for VTE should be advised to make lifestyle changes, as
appropriate, which may include weight loss, smoking cessation, and regular exercise.
Increased protein intake and supplementation with vitamin D and calcium do not
address the main risk factors for VTE
24. The nurse is caring for an acutely ill patient who is on anticoagulant therapy. The
patient has a comorbidity of renal insufficiency. How will this patients renal status affect
heparin therapy?
A) Heparin is contraindicated in the treatment of this patient.
B) Heparin may be administered subcutaneously, but not IV.
C) Lower doses of heparin are required for this patient.
D) Coumadin will be substituted for heparin.
Feedback: If renal insufficiency exists, lower doses of heparin are required. Coumadin
cannot be safely and. effectively used as a substitute and there is no contraindication
for IV administration.
25. The nurse is assessing a woman who is pregnant at 27 weeks gestation. The
patient is concerned about the recent emergence of varicose veins on the backs of her
calves. What is the nurses best response?
A) Facilitate a referral to a vascular surgeon.
B) Assess the patients ankle-brachial index (ABI) and perform Doppler ultrasound
testing.
C) Encourage the patient to increase her activity level.
D) Teach the patient that circulatory changes during pregnancy frequently cause
varicose veins.
Feedback: Pregnancy may cause varicosities because of hormonal effects related to
decreased venous outflow, increased pressure by the gravid uterus, and increased
blood volume. In most cases, no intervention or referral is necessary. This finding is not
an indication for ABI assessment and increased activity will not likely resolve the
problem.
26. Graduated compression stockings have been prescribed to treat a patients venous
insufficiency. What education should the nurse prioritize when introducing this
intervention to the patient?
A) The need to take anticoagulants concurrent with using compression stockings
B) The need to wear the stockings on a one day on, one day off schedule
C) The importance of wearing the stockings around the clock to ensure maximum
benefit
D) The importance of ensuring the stockings are applied evenly with no pressure points
Feedback: Any type of stocking can inadvertently become a tourniquet if applied
incorrectly (i. e, rolled tightly at the top). In sach instances, the stockings produce rather
than prevent stasis. For ambulatory patients, graduated compression stockings are
removed at night and reapplied before the legs are lowered from the bed to the floor in
the morning. They are used daily, not on alternating days. Anticoagulants are not
always indicated in patients who are using compression stockings.
27. The nurse caring for a patient with a leg ulcer has finished assessing the patient and
is developing a problem list prior to writing a plan of care. What major nursing diagnosis
might the care plan include?
A) Risk for disuse syndrome
B) Ineffective health maintenance
C) Sedentary lifestyle
D) Imbalanced nutrition: less than body requirements.
Feedback: Major nursing diagnoses for the patient with leg ulcers may include
imbalanced nutrition: less than body requirements, related to increased need for
nutrients that promote wound healing. Risk for disuse syndrome is a state in which an
individual is at risk for deterioration of body systems owing to prescribed or unavoidable
musculoskeletal inactivity. A leg ulcer will affect activity, but rarely to this degree. Leg
ulcers are not necessarily a consequence of ineffective health maintenance or
sedentary lifestyle.
28. How should the nurse best position a patient who has leg ulcers that are venous in
origin?
A) Keep the patients legs flat and straight.
B) Keep the patients knees bent to 45-degree angle and supported with pillows.
C) Elevate the patients lower extremities.
D) Dungle the patients legs over the side of the bed.
Feedback: Positioning of the legs depends on whether the ulcer is of arterial or venous
origin, With venous. insufficiency, dependent edema can be avoided by elevating the
lower extremities. Dangling the patients legs and applying pillows may further
compromise venous return.
29. A patient with advanced venous insufficiency is confined following orthopedic nurse
best prevent skin breakdown in the patients lower extremities? How can the surgery.
A) Ensure that the patients heels are protected and supported.
B) Closely monitor the patients serum albumin and prealbumin levels.
C) Perform gentle massage of the patients lower legs, as tolerated.
D) Perform passive range-of-motion exercises once per shift.
Feedback: If the patient is on bed rest, it is important to relieve pressure on the heels to
prevent pressure ulcerations, since the heels are among the most vulnerable body
regions. Monitoring blood work does not directly prevent skin breakdown, even though
albumin is related to wound healing. Massage is not normally indicated and may
exacerbate skin breakdown. Passive range-of-motion exercises do not directly reduce
the risk of skin breakdown.
30. The nurse has performed a thorough nursing assessment of the care of a patient
with chronic leg ulcers. The nurses assessment should include which of the following
components? Select all that apply.
A) Location and type of pain
B) Apical heart rate
C) Bilateral comparison of peripheral pulses
D) Comparison of temperature in the patients legs
E) Identification of mobility limitations
Feedback: A careful nursing history and assessment are important. The extent and type
of pain are carefully assessed, as are the appearance and temperature of the skin of
both legs. The quality of all peripheral pulses is assessed, and the pulses in both legs
are compared. Any limitation of mobility and activity that results from vascular
insufficiency is identified. Not likely is there any direct indication for assessment of
apical heart rate, although peripheral pulses must be assessed.
31. A nurse on a medical unit is caring for a patient who has been diagnosed with
lymphangitis. When reviewing this patients medication administration record, the nurse
should anticipate which of the following?
A) Coumadin (warfarin)
B) Lasix (furosemide)
C) An antibiotic
D) An antiplatelet aggregator
Feedback: Lymphangitis is an acute inflammation of the lymphatic channels caused by
an infectious process. Antibiotics are always a component of treatment. Diuretics are of
nominal use. Anticoagulants and antiplatelet aggregators are not indicated in this form
of infection.
32. A postsurgical patient has illuminated her call light to inform the nurse of a sudden
onset of lower leg pain. On inspection, the nurse observes that the patients left leg is
visibly swollen and reddened. What is the nurses most appropriate action?
A) Administer a PRN dose of subcutaneous heparin
B) Inform the physician that the patient has signs and symptoms of VTE.
C) Mobilize the patient promptly to dislodge any thrombi in the patients lower leg
D) Massage the patients lower leg to temporarily restore venous return.
Feedback: VTE requires prompt medical follow-up. Heparin will not dissolve an
established clot. Massaging the patients leg and mobilizing the patient would be
contraindicated because they would dislodge the clot, possibly resulting in a pulmonary
embolism.
33. A nurse is closely monitoring a patient who has recently been diagnosed with an
abdominal aortic aneurysm. What assessment finding would signal an impending
rupture of the patients aneurysm?
A) Sudden increase in blood pressure and a decrease in heart rate
B) Cessation of pulsating in an aneurysm that has previously been pulsating visibly
C) Sudden onset of severe back or abdominal pain
D) New onset of hemoptysis
Feedback: Signs of impending rupture include severe back or abdominal pain, which
may be persistent or intermittent. Impending rupture is not typically signaled by
increased blood pressure, bradycardia. cessation of pulsing, or hemoptysis.
34. A nurse is reviewing the physiological factors that affect a patients cardiovascular
health and tissue oxygenation. What is the systemic arteriovenous oxygen difference?
A) The average amount of oxygen removed by cach organ in the body
B) The amount of oxygen removed from the blood by the heart
C) The amount of oxygen returning to the lungs via the pulmonary artery
D) The amount of oxygen in aortic blood minus the amount of oxygen in the vena caval
blood
Feedback: The average amount of oxygen removed collectively by all of the body
tissues is about 25%. This means that the blood in the vena cava contains about 25%
less oxygen than aortic blood. This is known as the systemic arteriovenous oxygen
difference. The other answers do not apply
35. The nurse is evaluating a patients diagnosis of arterial insufficiency with reference to
the adequacy of the patients blood flow. On what physiological variables does adequate
blood flow depend? Select all that apply.
A) Efficiency of heart as a pump
B) Adequacy of circulating blood volume
C) Ratio of platelets to red blood cells
D) Size of red blood cells
E) Patency and responsiveness of the blood vessels
Feedback: Adequate blood flow depends on the efficiency of the heart as a pump, the
patency and responsiveness of the blood vessels, and the adequacy of circulating blood
volume. Adequacy of blood primarily depend on the size of red cells or their ratio to the
number of platelets.
36. A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot
feel the pulse in the patients left foot. How should the nurse proceed with assessment?
A) Have the primary care provider order a CT.
B) Apply a tourniquet for 3 to 5 minutes and then reassess.
C) Elevate the extremity and attempt to palpate the pulses.
D) Use Doppler ultrasound to identify the pulses.
Feedback: When pulses cannot be reliably palpated, a hand-held continuous wave
(CW) Doppler ultrasound device may be used to hear (insonate) the blood flow in
vessels. CT is not normally warranted and the application of a tourniquet poses health
risks and will not aid assessment. Elevating the extremity would make palpation more
difficult.
37. A medical nurse has admitted four patients over the course of a 12-hour shift. For
which patient would assessment of ankle-brachial index (ABI) be most clearly
warranted?
A) A patient who has peripheral edema secondary to chronic heart failure
B) An older adult patient who has a diagnosis of unstable angina
C) A patient with poorly controlled type I diabetes who is a smoker
D) A patient who has community-acquired pneumonia and a history of COPD
Feedback: Nurses should perform a baseline ABI on any patient with decreased pulses
or any patient 50 years of age or older with a history of diabetes or smoking. The other
answers do not apply.
38. An older adult patient has been treated for a venous ulcer and a plan is in place to
prevent the occurrence of future ulcers. What should the nurse include in this plan?
A) Use of supplementary oxygen to aid tissue oxygenation
B) Daily use of normal saline compresses on the lower limbs
C) Daily administration of prophylactic antibiotics
D) A high-protein diet that is rich in vitamins
Feedback: A diet that is high in protein, vitamins C and A, iron, and zine is encouraged
to promote healing and prevent future ulcers. Prophylactic antibiotics and saline
compresses are not used to prevent ulcers. Oxygen supplementation does not prevent
ulcer formation.
39. A 79-year-old man is admitted to the medical I unit with digital gangrene. The man
states that his problems first began when he stubbed his toe going to the bathroom in
the dark. In addition to this trauma, the nurse should suspect that the patient has a
history of what health problem?
A) Raynauds phenomenon
B) CAD
C) Arterial insufficiency
D) Varicose veins
Feedback: Arterial insufficiency may result in gangrene of the toe (digital gangrene),
which usually is caused by trauma. The toe is stubbed and then turns black. Raynauds,
CAD and varicose veins are not the usual causes of digital gangrene in the elderly.
40. When assessing venous disease in a patients lower extremities, the nurse knows
that what test will most likely be ordered?
A) Duplex ultrasonography
B) Echocardiography
C) Positron emission tomography (PET)
D) Radiography
Feedback: Duplex ultrasound may be used to determine the level and extent of venous
disease as well as its chronicity. Radiographs (x-rays), PET scanning, and
echocardiography are never used for this purpose as they do not allow visualization of
blood flow.