1. The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who ex- ercises regularly, reports
... [Show More] having pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation?
1. Heart rate 57 bpm.
2. SpO2 of 94% on room air.
3. Blood pressure 134/82.
4. Ankle-brachial index of 0.65.
2. A client with peripheral vascular disease has undergone a right femoralpopliteal bypass graft. The blood pressure has de- creased from 124/80 to 94/62. What should the nurse assess first?
1. IV fluid solution.
2. Pedal pulses.
3. Nasal cannula flow rate.
4. Capillary refill.
3. An overweight client taking warfarin (Coumadin) has dry skin due to de- creased
arterial blood flow. What should the nurse instruct the client to do? Select all that apply.
1. Apply lanolin or petroleum jelly to in- tact skin.
2. Follow a reduced-calorie, reduced-fat diet.
3. Inspect the involved areas daily for new ulcerations.
4. Instruct the client to limit activities of
4
2
1, 2, 3, 5
daily living (ADLs).
5. Use an electric razor to shave.
4. The nurse is caring for a client with pe- 3 ripheral artery disease who has recently been prescribed clopidogrel (Plavix). The nurse understands that more teaching is necessary when the client states which of the following:
1. "I should not be surprised if I bruise easier or if my gums bleed a little when brushing my teeth."
2. "It doesn't really matter if I take this medicine with or without food, whatever works best for my stomach."
3. "I should stop taking Plavix if it makes me feel weak and dizzy."
4. "The doctor prescribed this medicine to make my platelets less likely to stick together and help prevent clots from forming."
5. A client is receiving Cilostazol (Pletal) for 3 peripheral arterial disease causing intermittent claudication. The nurse de- termines this medication is effective
when the
client reports which of the following?
1. "I am having fewer aches and pains."
2. "I do not have headaches anymore."
3. "I am able to walk further without leg pain."
4. "My toes are turning grayish black in color."
6. The client admitted with peripheral vas- 1
cular disease (PVD) asks the nurse why
her legs hurt when she walks. The nurse bases a response on the knowledge that the
main characteristic of PVD is:
1. Decreased blood flow.
2. Increased blood flow.
3. Slow blood flow.
4. Thrombus formation.
7. The nurse is planning care for a client who is diagnosed with peripheral vascu- lar
disease (PVD) and has a history of heart failure. The nurse should develop a plan of
care that is based on the fact that the client may have a low tolerance for exer- cise
related to:
1. Decreased blood flow.
2. Increased blood flow.
3. Decreased pain.
4. Increased blood viscosity.
8. When assessing the lower extremities of a client with peripheral vascular
disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:
1. Competent venous valves.
2. Decreased blood volume.
3. Increase in muscular activity.
4. Increased venous pressure.
9. The nurse is obtaining the pulse of a client who has had a femoral-popliteal bypass surgery 6 hours ago. (See below)
1
4
4
The presence of a strong dor-
Which assessment provides the most ac- curate
information about the client's postopera- tive status?
10. The nurse is teaching a client about risk factors associated with atherosclerosis and how to reduce the risk. Which of the following is a risk factor that the client is not
able to modify?
1. Diabetes.
2. Age.
3. Exercise level.
4. Dietary preferences.
11. The nurse is assessing the lower extrem- ities of the client with peripheral vascular disease (PVD). During the as- sessment, the nurse should expect to find which of
the following clinical manifestations of PVD? Select all that apply.
salis pedis pulse indicates that there is circulation to
the extremity distal to the surgery indicating that the graft between the femoral and popliteal artery is allowing blood to circulate effectively. Answer 1 shows the nurse
obtaining the radial pulse; an- swer 2 shows the femoral pulse, which is proximal to the surgery site and will not indicate circulation distal to the surgery site. Answer 3 shows
the nurse obtaining an apical pulse.
CN: Reduction of risk potential; CL: Analyze
2
2
1. Hairy legs.
2. Mottled skin.
3. Pink skin.
4. Coolness.
5. Moist skin.
12. The nurse is unable to palpate the client's 3
left pedal pulses. Which of the following actions should the nurse take next?
1. Auscultate the pulses with a stetho- scope.
2. Call the physician.
3. Use a Doppler ultrasound device.
4. Inspect the lower left extremity.
13. Which of the following lipid abnormalities 3
is a risk factor for the development
of atherosclerosis and peripheral vascu- lar disease?
1. Low concentration of triglycerides.
2. High levels of high-density lipid (HDL) cholesterol.
3. High levels of low-density lipid (LDL) cholesterol.
4. Low levels of LDL cholesterol.
14. When assessing an individual with pe- 4 ripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg?
1. Aching pain in the left calf.
2. Burning pain in the left calf.
3. Numbness and tingling in the left leg.
4. Coldness of the left foot and ankle.
15. A client with peripheral vascular disease 2, 4, 3, 1
returns to the surgical care unit after having femoral-popliteal bypass grafting.
Indicate in which order the nurse should conduct assessment of this client.
1. Postoperative pain.
2. Peripheral pulses.
3. Urine output.
4. Incision site.
16. . A client with heart failure has bilateral +4 edema of the right ankle that extends
up to midcalf. The client is sitting in a chair with the legs in a dependent posi- tion.
Which of the following goals is the prior- ity? 1
1. Decrease venous congestion.
2. Maintain normal respirations.
3. Maintain body temperature.
4. Prevent injury to lower extremities.
17. . The nurse is assessing an older Cau- casian male who has a history of periph- eral
vascular disease. The nurse observes that the man's left great toe is black. The discoloration is probably a result of: 3
1. Atrophy.
2. Contraction.
3. Gangrene.
4. Rubor. [Show Less]