Quiz
Chapter 30
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Fragen in diesem Quiz (40)
1The 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’s subsequent care, the nurse should most likely address what health problem?
- ACoronary artery disease (CAD)
- BIntermittent claudication
- CArterial embolus
- DRaynaud’s disease
2While 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?
- AAssess the patient’s use of over-the-counter dietary supplements.
- BImplement interventions relevant to arterial narrowing.
- CEncourage the patient to increase intake of foods high in vitamin K.
- DAdjust the patient’s activity level to accommodate decreased coronary output.
3The 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?
- ANumbness and tingling in the distal extremities
- BUnequal peripheral pulses between extremities
- CVisible clubbing of the fingers and toes
- DReddened extremities with muscle atrophy
4The 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 nurse’s postoperative plan of care should include what intervention?
- AEarly ambulation and leg exercises
- BCessation of the oral contraceptives until 3 weeks postoperative
- CDoppler ultrasound of peripheral circulation twice daily
- DDependent positioning of the patient’s extremities when at rest
5A nurse is creating an education plan for a patient with venous insufficiency. What measure should the nurse include in the plan?
- AAvoiding tight-fitting socks.
- BLimit activity whenever possible.
- CSleep with legs in a dependent position.
- DAvoid the use of pressure stockings.
6The nurse is caring for a patient with a large venous leg ulcer. What intervention should the nurse implement to promote healing and prevent infection?
- AProvide a high-calorie, high-protein diet.
- BApply a clean occlusive dressing once daily and whenever soiled.
- CIrrigate the wound with hydrogen peroxide once daily.
- DApply an antibiotic ointment on the surrounding skin with each dressing change.
7The 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 nurse’s plan of care should prioritize what nursing diagnosis?
- ARisk for infection related to lymphedema
- BDisturbed body image related to lymphedema
- CIneffective health maintenance related to lymphedema
- DRisk for deficient fluid volume related to lymphedema
8An 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?
- ASit with crossed legs for a few minutes each hour to promote relaxation.
- BWalk for several minutes every hour to promote circulation.
- CElevate the legs when tired.
- DWear snug-fitting ankle socks to decrease edema.
9A 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?
- ACellulitis
- BLocal inflammation
- CElephantiasis
- DLymphangitis
10The triage nurse in the ED is assessing a patient who has presented with complaint of pain and swelling in her right lower leg. The patient’s 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?
- APlatelet transfusion to treat thrombocytopenia
- BWarfarin to treat arterial insufficiency
- CAntibiotics to treat cellulitis
- DHeparin IV to treat VTE
11A 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?
- AAoritis
- BDeep vein thrombosis
- CThoracic aortic aneurysm
- DRaynaud's disease
12A 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?
- AThe lack of exercise, which is the main cause of PAD.
- BThe likelihood that heavy alcohol intake is a significant risk factor for PAD.
- CCigarettes contain nicotine, which is a powerful vasoconstrictor and may cause or aggravate PAD.
- DAlcohol suppresses the immune system, creates high glucose levels, and may cause PAD.
13A 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?
- AElevate his legs and arms above his heart when resting.
- BEncourage the patient to engage in a moderate amount of exercise.
- CEncourage extended periods of sitting or standing.
- DDiscourage walking in order to limit pain.
14The 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 patient’s care plan should address what problem?
- ADecreased mobility related to VTE
- BAcute pain related to intermittent claudication
- CDecreased mobility related to venous insufficiency
- DAcute pain related to vasculitis
15A nurse in the rehabilitation unit is caring for an older adult patient who is in cardiac rehabilitation following an MI. The nurse’s 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.”
- BWalking 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 self-esteem.”
- D“When you walk, the muscles in your legs contract and pump the blood in your veins back toward your heart, which allows more blood to return to your heart.”
16The 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 patient’s wound?
- AHemorrhage
- BHeavy exudate
- CDeep wound bed
- DPale-colored wound bed
17The nurse is preparing to administer warfarin (Coumadin) to a client with deep vein thrombophlebitis (DVT). Which laboratory value would most clearly indicate that the patient’s warfarin is at therapeutic levels?
- APartial thromboplastin time (PTT) within normal reference range
- BProthrombin time (PT) eight to ten times the control
- CInternational normalized ratio (INR) between 2 and 3
- DHematocrit of 32%
18The clinic nurse is caring for a 57-year-old client who reports experiencing leg 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.”
19A 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?
- AAssess pulse of affected extremity every 15 minutes at first.
- BPalpate the affected leg for pain during every assessment.
- CAssess the patient for signs and symptoms of compartment syndrome every 2 hours.
- DPerform Doppler evaluation once daily.
20You are caring for a patient who is diagnosed with Raynaud’s phenomenon. The nurse should plan interventions to address what nursing diagnosis?
- AChronic pain
- BIneffective tissue perfusion
- CImpaired skin integrity
- DRisk for injury
21A patient presents to the clinic complaining of the inability to grasp objects with her right hand. The patient’s 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?
- ALymphedema
- BRaynaud’s phenomenon
- CUpper extremity arterial occlusive disease
- DUpper extremity VTE
22A 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 resident’s 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?
- AChronic venous insufficiency
- BRaynaud’s phenomenon
- CVTE
- DPAD
23The 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.
- AHigh-protein diet
- BWeight loss
- CRegular exercise
- DSmoking cessation
- ECalcium and vitamin D supplementation
24The nurse is caring for an acutely ill patient who is on anticoagulant therapy. The patient has a comorbidity of renal insufficiency. How will this patient’s renal status affect heparin therapy?
- AHeparin is contraindicated in the treatment of this patient.
- BHeparin may be administered subcutaneously, but not IV.
- CLower doses of heparin are required for this patient.
- DCoumadin will be substituted for heparin.
25The 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 nurse’s best response?
- AFacilitate a referral to a vascular surgeon.
- BAssess the patient’s ankle-brachial index (ABI) and perform Doppler ultrasound testing.
- CEncourage the patient to increase her activity level.
- DTeach the patient that circulatory changes during pregnancy frequently cause varicose veins.
26Graduated compression stockings have been prescribed to treat a patient’s venous insufficiency. What education should the nurse prioritize when introducing this intervention to the patient?
- AThe need to take anticoagulants concurrent with using compression stockings
- BThe need to wear the stockings on a “one day on, one day off” schedule
- CThe importance of wearing the stockings around the clock to ensure maximum benefit
- DThe importance of ensuring the stockings are applied evenly with no pressure points
27The 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?
- ARisk for disuse syndrome
- BIneffective health maintenance
- CSedentary lifestyle
- DImbalanced nutrition: less than body requirements
28How should the nurse best position a patient who has leg ulcers that are venous in origin?
- AKeep the patient’s legs flat and straight.
- BKeep the patient’s knees bent to 45-degree angle and supported with pillows.
- CElevate the patient’s lower extremities.
- DDangle the patient’s legs over the side of the bed.
29A patient with advanced venous insufficiency is confined following orthopedic surgery. How can the nurse best prevent skin breakdown in the patient’s lower extremities?
- AEnsure that the patient’s heels are protected and supported.
- BClosely monitor the patient’s serum albumin and prealbumin levels.
- CPerform gentle massage of the patient’s lower legs, as tolerated.
- DPerform passive range-of-motion exercises once per shift.
30The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers. The nurse’s assessment should include which of the following components? Select all that apply.
- ALocation and type of pain
- BApical heart rate
- CBilateral comparison of peripheral pulses
- DComparison of temperature in the patient’s legs
- EIdentification of mobility limitations
31A nurse on a medical unit is caring for a patient who has been diagnosed with lymphangitis. When reviewing this patient’s medication administration record, the nurse should anticipate which of the following?
- ACoumadin (warfarin)
- BLasix (furosemide)
- CAn antibiotic
- DAn antiplatelet aggregator
32A 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 patient’s left leg is visibly swollen and reddened. What is the nurse’s most appropriate action?
- AAdminister a PRN dose of subcutaneous heparin.
- BInform the physician that the patient has signs and symptoms of VTE.
- CMobilize the patient promptly to dislodge any thrombi in the patient’s lower leg.
- DMassage the patient’s lower leg to temporarily restore venous return.
33A 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 patient’s aneurysm?
- ASudden increase in blood pressure and a decrease in heart rate
- BCessation of pulsating in an aneurysm that has previously been pulsating visibly
- CSudden onset of severe back or abdominal pain
- DNew onset of hemoptysis
34A nurse is reviewing the physiological factors that affect a patient’s cardiovascular health and tissue oxygenation. What is the systemic arteriovenous oxygen difference?
- AThe average amount of oxygen removed by each organ in the body
- BThe amount of oxygen removed from the blood by the heart
- CThe amount of oxygen returning to the lungs via the pulmonary artery
- DThe amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood
35The nurse is evaluating a patient’s diagnosis of arterial insufficiency with reference to the adequacy of the patient’s blood flow. On what physiological variables does adequate blood flow depend? Select all that apply.
- AEfficiency of heart as a pump
- BAdequacy of circulating blood volume
- CRatio of platelets to red blood cells
- DSize of red blood cells
- EPatency and responsiveness of the blood vessels
36A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the pulse in the patient’s left foot. How should the nurse proceed with assessment?
- AHave the primary care provider order a CT.
- BApply a tourniquet for 3 to 5 minutes and then reassess.
- CElevate the extremity and attempt to palpate the pulses.
- DUse Doppler ultrasound to identify the pulses.
37A 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?
- AA patient who has peripheral edema secondary to chronic heart failure
- BAn older adult patient who has a diagnosis of unstable angina
- CA patient with poorly controlled type 1 diabetes who is a smoker
- DA patient who has community-acquired pneumonia and a history of COPD
38An 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?
- AUse of supplementary oxygen to aid tissue oxygenation
- BDaily use of normal saline compresses on the lower limbs
- CDaily administration of prophylactic antibiotics
- DA high-protein diet that is rich in vitamins
39A 79-year-old man is admitted to the medical 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?
- ARaynaud’s phenomenon
- BCAD
- CArterial insufficiency
- DVaricose veins
40When assessing venous disease in a patient’s lower extremities, the nurse knows that what test will most likely be ordered?
- ADuplex ultrasonography
- BEchocardiography
- CPositron emission tomography (PET)
- DRadiography
Informationen
- Beschreibung
- Nursing (Cardiac) Quiz am Chapter 30, erstellt von Jessica Levine am 06/10/2016.
- Autor
- Jessica Levine
- Sprache
- English
- Aufrufe
- 106
- Schlagwörter
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