NCLEX Practice Questions — Set 49
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac catheterization?
Show answer and rationale
Correct answer: D. Observe the puncture site for swelling and bleeding.
Assessment of circulatory status, including observation of the puncture site, is of primary importance after a cardiac catheterization. Laboratory values and skin warmth and turgor are important to monitor but are not the most important initial nursing assessment. Neurologic assessment every 15 minutes is not required.
A client experiences initial indications of excitation after having an IV infusion of lidocaine hydrochloride started. The nurse should further assess the client when the client reports having:
Show answer and rationale
Correct answer: B. Tinnitus.
Common adverse effects of lidocaine hydrochloride include dizziness, tinnitus, blurred vision, tremors, numbness and tingling of extremities, excessive perspiration, hypotension, seizures, and finally coma. Cardiac effects include slowed conduction and cardiac arrest. Palpitations, urinary frequency, and lethargy are not considered typical adverse reactions to lidocaine.
A pulmonary artery catheter is inserted in a client with severe mitral stenosis and regurgitation. The nurse administers furosemide (Lasix) to treat pulmonary congestion and begins a Nitroprusside (Nipride) drip per physician prescriptions. The nurse notices a sudden drop in the pulmonary artery diastolic pressure and pulmonary artery wedge pressure. The nurse should first assess:
Show answer and rationale
Correct answer: A. Blood pressure.
The nurse should immediately assess the blood pressure since Nipride and Lasix can cause severe hypotension from a decrease in preload and afterload. If the client is hypotensive, the Nipride dose should be reduced or discontinued. Urine output should then be monitored to make sure there is adequate renal perfusion. A 12-lead EKG is performed if the client experiences chest pain. A reduction in pulmonary artery pressures should improve the pulmonary congestion and lung sounds.
A client has mitral stenosis and will have a valve replacement. The nurse is instructing the client about health maintenance prior to surgery. Inability to follow which of the following regimens would pose the greatest health hazard to this client at this time?
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Correct answer: C. Medication therapy.
Preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart disease to prevent emboli. Postoperatively, all clients with mechanical valves and some clients with bioprosthesis are maintained indefinitely on anticoagulant therapy. Adhering strictly to a dosage schedule and observing specific precautions are necessary to prevent hemorrhage or thromboembolism. Some clients are maintained on lifelong antibiotic prophylaxis to prevent recurrence of rheumatic fever. Episodic prophylaxis is required to prevent infective endocarditis after dental procedures or upper respiratory, gastrointestinal, or genitourinary tract surgery. Diet modification, activity restrictions, and dental care are important; however, they do not have as much significance postoperatively as medication therapy does.
A client who has undergone a mitral valve replacement has persistent bleeding from the sternal incision during the early postoperative period. The nurse should do which of the following?
Show answer and rationale
Correct answer: A. All of the above
The hemoglobin and hematocrit should be assessed to evaluate blood loss. An elevated INR and PTT and decreased platelet count increase the risk for bleeding. The client may require blood products depending on lab values and severity of bleeding; therefore, availability of blood products should be confirmed by calling the blood bank. Close monitoring of blood loss from the mediastinal chest tubes should be done. Warfarin is an anticoagulant that will increase bleeding. Anticoagulation should be held at this time. Information is needed on the type of valve replacement. For a mechanical heart valve, the INR is kept at 2 to 3.5. Tissue valves do not require anticoagulation. Dopamine should NOT be initiated if the client is hypotensive from hypovolemia. Fluid volume assessment should always be done first. Volume replacement should be initiated in a hypovolemic client prior to starting an inotrope such as dopamine.
The most effective measure the nurse can use to prevent wound infection when changing a client’s dressing after coronary artery bypass surgery is to:
Show answer and rationale
Correct answer: A. Observe careful handwashing procedures.
Many factors help prevent wound infections, including washing hands carefully, using sterile prepackaged supplies and equipment, cleaning the incisional area well, and disposing of soiled dressings properly. However, most authorities say that the single most effective measure in preventing wound infections is to wash the hands carefully before and after changing dressings. Careful hand washing is also important in reducing other infections often acquired in hospitals, such as urinary tract and respiratory tract infections.
For a client who excretes excessive amounts of calcium during the postoperative period after open heart surgery, which of the following measures should the nurse institute to help prevent complications associated with excessive calcium excretion?
Show answer and rationale
Correct answer: C. Ensure a liberal fluid intake.
In an immobilized client, calcium leaves the bone and concentrates in the extracellular fluid. When a large amount of calcium passes through the kidneys, calcium can precipitate and form calculi. Nursing interventions that help prevent calculi include ensuring a liberal fluid intake (unless contraindicated). A diet rich in acid should be provided to keep the urine acidic, which increases the solubility of calcium. Preventing constipation is not associated with excessive calcium excretion. Limiting foods rich in calcium, such as dairy products, will help in preventing renal calculi.
The nurse should teach the client who is receiving warfarin sodium that:
Show answer and rationale
Correct answer: B. International Normalized Ratio (INR) is used to assess effectiveness.
INR is the value used to assess effectiveness of the warfarin sodium therapy. INR is the prothrombin time ratio that would be obtained if the thromboplastin reagent from the World Health Organization was used for the plasma test. It is now the recommended method to monitor effectiveness of warfarin sodium. Generally, the INR for clients administered warfarin sodium should range from 2 to 3. In the past, prothrombin time was used to assess effectiveness of warfarin sodium and was maintained at 1.5 to 2.5 times the control value. Partial thromboplastin time is used to assess the effectiveness of heparin therapy. Fresh frozen plasma or vitamin K is used to reverse warfarin sodium’s anticoagulant effect, whereas protamine sulfate reverses the effects of heparin. Warfarin sodium will help to prevent blood clots.
Good dental care is an important measure in reducing the risk of endocarditis. A teaching plan to promote good dental care in a client with mitral stenosis should include instructing the client to do which of the following?
Show answer and rationale
Correct answer: B. All of the above
Daily dental care including brushing the teeth twice a day and flossing once a day and frequent checkups by a dentist who is informed about the client’s condition are required to maintain good oral health. The client can use a regular tooth brush; it is not necessary to avoid use of an electric toothbrush. Taking antibiotics prior to certain dental procedures is recommended only if the client has a prosthetic valve or a heart transplant. It is not necessary to use an antibiotic mouthwash.
Before a client’s discharge after mitral valve replacement surgery, the nurse should evaluate the client’s understanding of postsurgery activity restrictions. Which of the following should the client not engage in until after the 1-month postdischarge appointment with the surgeon?
Show answer and rationale
Correct answer: C. Lifting anything heavier than 10 lb (4.5 kg).
Most cardiac surgical clients have median sternotomy incisions, which take about 3 months to heal. Measures that promote healing include avoiding heavy lifting, performing muscle reconditioning exercises, and using caution when driving. Showering or bathing is allowed as long as the incision is well approximated with no open areas or drainage. Activities should be gradually resumed on discharge.
Three days after mitral valve replacement surgery, the client tells the nurse there is a "clicking" noise coming from the chest incision and the incision seems to becoming larger. The nurse’s response should reflect the understanding that the client may be experiencing which of the following?
Show answer and rationale
Correct answer: C. Anxiety related to altered body image.
Verbalized concerns from this client may stem from anxiety over the changes in the body after open heart surgery. Although the client may experience anxiety related to altered health status or may have a lack of knowledge regarding the postoperative course, the client is pointing out the changes in the body image. The client is not concerned about altered tissue perfusion.
Which set of postural vital signs (BP and heart rate) indicate inadequate blood volume?
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Correct answer: B. Supine 120/70, 70., Sitting 102/64, 86.;Standing 100/60, 92.
There was a significant change in both blood pressure and heart rate with position change. This indicates inadequate blood volume to sustain normal values. Normal postural changes allow for an increase in heart rate of 5 to 20 bpm, a possible slight decrease of less than 5 mm Hg in the systolic blood pressure, and a possible slight increase of less than 5 mm Hg in the diastolic blood pressure.
A client is taking clonidine (Catapres) for treatment of hypertension. The nurse should teach the client about which of the following common adverse effects of this drug?
Show answer and rationale
Correct answer: A. All of the above
Clonidine (Catapres) is a central-acting adrenergic antagonist. It reduces sympathetic outflow from the central nervous system. Dry mouth, impotence, and sleep disturbances are possible adverse effects. Hyperkalemia and pancreatitis are not anticipated with use of this drug.
The nurse is discussing medications with a client with hypertension who has a prescription for furosemide (Lasix) daily. The client needs further education when the client states which of the following?
Show answer and rationale
Correct answer: B. "I know I should not drive after taking my Lasix."
Furosemide (Lasix) is a diuretic often prescribed for clients with hypertension or heart failure; the drug should not affect a client’s ability to drive safely. Lasix may cause orthostatic hypotension and clients should be instructed to be careful when changing from supine to sitting to standing position. Diuretics should be taken in the morning if possible to prevent sleep disturbance due to the need to get up to void. Lasix is a loop diuretic that is not potassium sparing; clients should take potassium supplements as prescribed and have their serum potassium levels checked at prescribed intervals.
In teaching the client with hypertension to avoid orthostatic hypotension, the nurse should emphasize which of the following instructions?
Show answer and rationale
Correct answer: B. Both of the above
Changing positions slowly and avoiding long periods of standing may limit the occurrence of orthostatic hypotension. Scheduling regular medication times is important for blood pressure management, but this aspect is not related to the development of orthostatic hypotension. Excessive alcohol intake and hot baths are associated with vasodilation.
The nurse teaches a client who has recently been diagnosed with hypertension about following a low-calorie, low-fat, low-sodium diet. Which of the following menu selections would best meet the client’s needs?
Show answer and rationale
Correct answer: D. Baked chicken, an apple, and a slice of white bread.
Processed and cured meat products, such as cold cuts, ham, and hot dogs, are all high in both fat and sodium and should be avoided on a low-calorie, low-fat, low-salt diet. Dietary restrictions of all types are complex and difficult to implement with clients who are basically asymptomatic.
A client who has diabetes is taking metoprolol (Lopressor) for hypertension. Which of the following information should the nurse include in the teaching plan?
Show answer and rationale
Correct answer: B. All of the above
Metoprolol (Lopressor) is a beta-adrenergic blocker indicated for hypertension, angina, and myocardial infarction. The tablets should be taken with food at same time each day; they should not be chewed or crushed. The health care provider should be notified if pulse falls below 50 for several days. Blood glucose should be checked regularly during therapy since increased episodes of hypoglycemia may occur. It may mask evidence of hypoglycemia such as palpitations, tachycardia, and tremor. Use of any OTC decongestants, asthma and cold remedies, and herbal preparations must be avoided. Fainting spells may occur due to exercise or stress, and the dosage of the drug may need to be reduced or discontinued.
An older adult with a history of hypertension is admitted with diagnosis of dehydration. The client is becoming increasingly confused and weak. The client reports taking one tablet of hydrochlorothiazide (HydroDIURIL) daily, and the prescription is written for 1/2 tablet. The nurse should obtain additional information about:
Show answer and rationale
Correct answer: D. Decreased hepatic blood flow.
Aging causes decreased hepatic blood flow. Decreased drug metabolism, which occurs with aging, along with more drug in circulation means the drug will remain in the body longer and produce greater drug effects. The client has also taken more drug than prescribed increasing the opportunity for more drug action to occur. When there is decreased metabolism of drugs, an increase in the half-life will occur most especially in the older adult. In older adults transit time (GI motility) is slower, allowing more drug to be absorbed. Increased urinary elimination would mean that drug elimination could be higher not lower and accumulating in the body.
A client diagnosed with primary (essential) hypertension is taking chlorothiazide (Diuril). The nurse determines teaching about this medication is effective when the client makes the following statement. "I will
Show answer and rationale
Correct answer: D. All of the above
Chlorothiazide (Diuril) causes increased urination and decreased swelling (if there is edema) and weight loss. It is important to check and record weight two to three times per week at same time of day with similar amount of clothing. Clients should not drink alcoholic beverages or take other medications without the approval of the health care provider. Reducing sodium intake in the diet helps diuretic drugs to be more effective and allows smaller doses to be taken. Smaller doses are less likely to cause adverse effects and hence excessive table salt as well as salty foods should be avoided. Chlorothiazide (Diuril) is a diuretic that is prescribed for lower blood pressure and may cause dizziness and faintness when the patient stands up suddenly. This can be prevented or decreased by changing positions slowly. If dizziness is severe, the health care provider must be notified. Diuretics may cause sensitivity to sunlight, hence the need to avoid prolonged exposure to sunlight, use sunscreens, and wear protective clothing. Chlorothiazide (Diuril) causes increased urination and must be taken early in the day to decrease nighttime trips to the bathroom. Fewer bathroom trips mean less interference with sleep and less risk of falls.
Which intervention would be most likely to assist the client with hypertension in maintaining an exercise program?
Show answer and rationale
Correct answer: C. Tailoring a program to the client’s needs and abilities.
Tailoring or individualizing a program to the client’s lifestyle has been shown to be an effective strategy for changing health behaviors. Providing a written program, explaining the program to the client’s spouse, and reassuring the client that he or she can do the program may be helpful but are not as likely to promote adherence as individualizing the program.
The client realizes the importance of quitting smoking, and the nurse develops a plan to help the client achieve this goal. Which of the following nursing interventions should be the initial step in this plan?
Show answer and rationale
Correct answer: C. Establish the client’s daily smoking pattern.
A plan to reduce or stop smoking begins with establishing the client’s personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior.
When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol:
Show answer and rationale
Correct answer: B. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction.
Propranolol is a beta-adrenergic blocking agent. Actions of propranolol include reducing heart rate, decreasing myocardial contractility, and slowing conduction. Propranolol does not increase norepinephrine secretion, cause vasodilation, or block conversion of angiotensin I to angiotensin II.
The most important long-term goal for a client with hypertension is to:
Show answer and rationale
Correct answer: D. Make a commitment to long-term therapy.
Compliance is the most critical element of hypertension therapy. In most cases, hypertensive clients require lifelong treatment and their hypertension cannot be managed successfully without drug therapy. Stress management is an important component of hypertension therapy, but the priority goal is related to compliance. It is not necessary for the client to change jobs or retire, but rather to learn to manage stress if the job is stressful. Losing weight may be necessary and will contribute to lower blood pressure, but the client must first accept the need for a lifelong management plan to control the hypertension.
The client has had hypertension for 20 years. The nurse should assess the client for:
Show answer and rationale
Correct answer: C. Renal insufficiency and failure.
Renal disease, including renal insufficiency and failure, is a complication of hypertension. Effective treatment of hypertension assists in preventing this complication. Valvular heart disease, endocarditis, and peptic ulcer disease are not complications of hypertension.
The nurse is developing a care plan with an older adult with hypertension and is instructing the client that hypertension can be a "silent killer." The nurse should instruct the client to report signs of which of the following diseases that are often a result of undetected high blood pressure?
Show answer and rationale
Correct answer: A. Cerebrovascular accidents (CVAs).
Hypertension is referred to as the silent killer for adults, because until the adult has significant damage to other systems, the hypertension may go undetected. CVAs can be related to long-term hypertension. Liver or pulmonary disease is not generally associated with hypertension. Myocardial infarction is generally related to coronary artery disease.
A hospitalized client who is being treated for hypertension with furosemide (Lasix), atenolol (Tenormin), and ramipril (Altace) develops a second-degree heart block Mobitz type 1. Which of the following actions should the nurse take?
Show answer and rationale
Correct answer: A. Withhold the atenolol.
The client may be asymptomatic and the underlying cause should be assessed. Drugs that block the AV node should be avoided, such as beta blockers (Atenolol), calcium channel blockers, digoxin, and amiodarone. Symptomatic clients are treated with atropine and transcutaneous pacing. There is no indication for a fluid bolus, cardioversion, or arterial line.
When teaching the client about complications of atrial fibrillation, the nurse should instruct the client to avoid which of the following?
Show answer and rationale
Correct answer: D. Stasis of blood in the atria.
Atrial fibrillation occurs when the sinoatrial node no longer functions as the heart’s pacemaker and impulses are initiated at sites within the atria. Because conduction through the atria is disturbed, atrial contractions are reduced and stasis of blood in the atria occurs, predisposing to emboli. Some estimates predict that 30% of clients with atrial fibrillation develop emboli. Atrial fibrillation is not associated with increased cardiac output, elevated blood pressure, or decreased pulse rate; rather, it is associated with an increased pulse rate.
When teaching a client about self-care following placement of a new permanent pacemaker to the left upper chest, the nurse should include which information?
Show answer and rationale
Correct answer: D. Both of the above
The nurse must teach the client how to take and record the pulse daily. The client should be instructed to avoid lifting the operative-side arm above shoulder level for 1 week postinsertion. It takes up to 2 months for the incision site to heal and full range of motion to return. The client should avoid heavy lifting until approved by the physician. The pacemaker metal casing does not set off airport security alarms, so there are no travel restrictions. Prolonged immobilization is not required. Microwave ovens are safe to use and do not alter pacemaker function.
A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client’s cardiac monitor. The client has a blood pressure of 90/60. The nurse should take which of the following actions first?
Show answer and rationale
Correct answer: D. Prepare for transcutaneous pacing.
Transcutaneous pacemaker therapy provides an adequate heart rate to a client in an emergency situation. Defibrillation and a lidocaine infusion are not indicated for the treatment of third-degree heart block. Transcutaneous pacing is used temporarily until a transvenous or permanent pacemaker can be inserted.
An older adult is admitted to the telemetry unit for placement of a permanent pacemaker because of sinus bradycardia. A priority goal for the client within 24 hours after insertion of a permanent pacemaker is to:
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Correct answer: A. Maintain cardiac conduction stability.
Maintaining cardiac conduction stability to prevent arrhythmias is a priority immediately after artificial pacemaker implantation. The client should have continuous electrocardiographic monitoring until proper pacemaker functioning is verified. Skin integrity, while important, is not an immediate concern. The pacemaker is used to increase heart rate and cardiac output, not decrease it. The client should limit activity for the first 24 to 48 hours after pacemaker insertion. The client should also restrict movement of the affected extremity for 24 hours.
The client who had a permanent pacemaker implanted 2 days earlier is being discharged from the hospital. The client understands the discharge plan when the client:
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Correct answer: D. Verbalizes safety precautions needed to prevent pacemaker malfunction.
Education is a major component of the discharge plan for a client with an artificial pacemaker. The client with a permanent pacemaker needs to be able to state specific information about safety precautions, such as to refrain from lifting more than 3 lb (1.35 kg) or stretching and bending and to count the pulse once per week, that are necessary to maintain proper pacemaker function. The client will not necessarily be placed on a low cholesterol diet. The client should resume activities as he is able, and does not need to remain on bed rest. The client should know signs and symptoms of MI, but is not at risk because of the pacemaker.
The nurse is preparing the client for cardioversion. The nurse should do which of the following?
Show answer and rationale
Correct answer: D. All of the above
The nurse should first explain the procedure to the client, and then place the patch electrodes per agency procedure. The nurse must make sure to call "clear" before discharging the electrical current to prevent injury to others who may be helping with the procedure. After the procedure, the nurse must record the amount of electrical current delivered and the resulting rhythm. The paddles are placed on the patch adhered to the client’s skin, not over the client’s clothing.
A client who has been given cardiopulmonary resuscitation (CPR) is transported by ambulance to the hospital’s emergency department, where the admitting nurse quickly assesses the client’s condition. The most effective way to determine the effectiveness of CPR is noting whether the:
Show answer and rationale
Correct answer: C. Pupils are reacting to light.
Pupillary reaction is the best indication of whether oxygenated blood has been reaching the client’s brain. Pupils that remain widely dilated and do not react to light probably indicate that serious brain damage has occurred. The pulse rate may be normal, mucous membranes may still be pink, and systolic blood pressure may be 80 mm Hg or higher, and serious brain damage may still have occurred.
A client is given amiodarone (Cordarone) in the emergency department for a dysrhythmia. Which of the following indicates the drug is having the desired effect?
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Correct answer: B. The number of premature ventricular contractions is decreasing.
Amiodarone is used for the treatment of premature ventricular contractions, ventricular tachycardia with a pulse, atrial fibrillation, and atrial flutter. Amiodarone is not used as initial therapy for a pulseless dysrhythmia.
During cardiopulmonary resuscitation (CPR), the xiphoid process at the lower end of the sternum should not be compressed when performing cardiac compressions. Which of the following organs would be most likely at risk for laceration by forceful compressions over the xiphoid process?
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Correct answer: A. Liver.
Because of its location near the xiphoid process, the liver is the organ most easily damaged from pressure exerted over the xiphoid process during CPR. The pressure on the victim’s chest wall should be sufficient to compress the heart but not so great as to damage internal organs. Injury may result, however, even when CPR is performed properly.
When performing external chest compressions on an adult during cardiopulmonary resuscitation (CPR), the rescuer should depress the sternum:
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Correct answer: B. 2 inches (7.5 cm)
An adult’s sternum must be depressed 2 inches (5 cm) with each compression to ensure adequate heart compression.
If a client is receiving rescue breaths and the chest wall fails to rise during cardiopulmonary resuscitation, the rescuer should first:
Show answer and rationale
Correct answer: C. Reposition the airway.
If the chest wall is not rising with rescue breaths, the head should be repositioned first to ensure that the airway is adequately opened. A bag-mask device allows for delivery of 100% oxygen, but is difficult to manage if there is just one rescuer; ideally two persons are used to operate the bag-mask device, one to maintain the seal and the other to provide the ventilations. Compressions should be maintained at 100 per minute.
During rescue breathing in cardiopulmonary resuscitation (CPR), the victim will exhale by:
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Correct answer: B. Turning the head to the side.
The exhalation phase of ventilation is a passive activity that occurs during CPR as part of the normal relaxation of the victim’s chest. No action by the rescuer is necessary.
The rapid response team has been called to manage an unwitnessed cardiac arrest in a client’s hospital room. The estimated maximum time a person can be without cardiopulmonary function and still not experience permanent brain damage is:
Show answer and rationale
Correct answer: C. 4 to 6 minutes.
After a person is without cardiopulmonary function for 4 to 6 minutes, permanent brain damage is almost certain. To prevent permanent brain damage, it is important to begin CPR promptly after a cardiopulmonary arrest.
When performing the Heimlich maneuver on a conscious adult victim, the rescuer delivers inward and upward thrusts specifically:
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Correct answer: B. Below the xiphoid process and above the umbilicus.
The thrusts should be delivered below the xiphoid process, but above the umbilicus, to minimize the risk of internal injuries.
The nurse is caring for a client whose condition has been deteriorating. The client becomes unresponsive, the blood pressure is 80/40, and SpO2 is 90% on 50% face mask. The nurse should:
Show answer and rationale
Correct answer: D. Call the rapid response team.
The rapid response team should be called immediately to evaluate and treat the client. There is no indication at this time for manual ventilations or chest compressions. If the family is not interfering in client care, it can be reassuring to the family to see that all possible care is being provided.
The nursing assistant reports to the nurse that a client is "feeling short of breath." The client’s blood pressure was 124/78 2 hours ago with a heart rate of 82; the nursing assistant reports that blood pressure is now 84/44 with a heart rate of 54 and the client stated, "I just don’t feel good." Which of the following interventions should the nurse initiate?
Show answer and rationale
Correct answer: C. All of the above
The nurse must have assessment data and verify vital signs if necessary in order to determine the action that is required. If there is a significant change in the client’s condition, the charge nurse should be notified in order to help the nurse with both this client and the nurse’s other assigned clients if necessary; most acute care facilities have a rapid response team that can also help assess and intervene with basic standing orders if necessary. Positioning the client in semi-Fowler’s is a nursing action that may assist in breathing and relieve shortness of breath. It is important for the nurse to reassure the client by staying calm and remaining with the client. The physician must be notified of the change in client’s condition; the nurse must have all information available and present it to the physician in a concise and accurate manner using SBAR format including a recommendation for treatment if indicated. The nurse should stay with this client and delegate checking on other assigned clients to the charge nurse or nursing assistant.
The nurse is tracking data on a group of clients with heart failure who have been discharged from the hospital and are being followed at a clinic. Which of the following data indicate that nursing interventions of monitoring and teaching have been effective?
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Correct answer: C. Five percent of the clients required hospitalization in the last 90 days.
The goals of managing clients outside of the hospital are for the clients to maintain health and prevent readmission, thus interventions, such as monitoring and teaching, appear to have contributed to the low readmission rate in this group of clients. Although it is important that clients do not gain weight, view educational material, and continue to take their medication, the primary indicator of effectiveness of the program is the lack of re-hospitalization.
The nurse in the intensive care unit is giving a report to the nurse in a cardiac step-down unit about a client who had coronary artery bypass surgery. Which of the following is the most effective way to assure essential information about the client is reported?
Show answer and rationale
Correct answer: A. Use a printed checklist with information individualized for the client.
Using an individualized, printed checklist ensures that all key information is reported; the checklist can then serve as a record to which nurses can refer later. Giving a verbal report leaves room for error in memory; using an audiotape or an electronic health record requires nurses to spend unnecessary time retrieving information.
The nurse is planning care for elderly clients who are affected by orthostatic hypotension. The nurse should do which of the following?
Show answer and rationale
Correct answer: C. All of the above
Orthostatic hypotension is a drop in blood pressure that occurs when changing position, usually to a more upright position. Orthostatic hypotension often occurs in elderly clients, and it is a common cause of falls. Nurses must assess clients for orthostatic hypotension, and assist all clients with orthostatic hypotension in standing to help prevent falls. Lower limb compression devices aid in prevention of decreased orthostatic systolic blood pressure and reduce symptoms in elderly clients with progressive orthostatic hypotension. Nurses must teach clients how to gradually change their position, and they must conduct "fall risk" assessments. Sequential compression devices may be helpful to high-risk clients and should be considered when developing the care plan. Antihypertensive medications are not necessary for clients with orthostatic hypertension and may precipitate dangerous drops in blood pressure. The clients should be encouraged to be ambulatory.
The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation?
Show answer and rationale
Correct answer: C. Ankle-brachial index of 0.65.
An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular disease in a client who is experiencing intermittent claudication. A Doppler ultrasound is indicated for further evaluation. The bradycardic heart rate is acceptable in an athletic client with a normal blood pressure. The SpO2 is acceptable; the client has a smoking history.
A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 to 94/62. What should the nurse assess first?
Show answer and rationale
Correct answer: C. Pedal pulses.
With each set of vital signs, the nurse should assess the dorsalis pedis and posterior tibial pulses. The nurse needs to ensure adequate perfusion to the lower extremity with the drop in blood pressure. IV fluids, nasal cannula setting, and capillary refill are important to assess; however, priority is to determine the cause of drop in blood pressure and that adequate perfusion through the new graft is maintained.
An overweight client taking warfarin (Coumadin) has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do?
Show answer and rationale
Correct answer: A. All of the above
Maintaining skin integrity is important in preventing chronic ulcers and infections. The client should be taught to inspect the skin on a daily basis. The client should reduce weight to promote circulation; a diet lower in calories and fat is appropriate. Because the client is receiving Coumadin, the client is at risk for bleeding from cuts. To decrease the risk of cuts, the nurse should suggest that the client use an electric razor. The client with decreased arterial blood flow should be encouraged to participate in ADLs. In fact, the client should be encouraged to consult an exercise physiologist for an exercise program that enhances the aerobic capacity of the body.
The nurse is caring for a client with peripheral 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:
Show answer and rationale
Correct answer: B. "I should stop taking Plavix if it makes me feel weak and dizzy."
Weakness, dizziness, and headache are common adverse effects of Plavix and the client should report these to the physician if they are problematic; in order to decrease risk of clot formation, Plavix must be taken regularly and should not be stopped or taken intermittently. The main adverse effect of Plavix is bleeding, which often occurs as increased bruising or bleeding when brushing teeth. Plavix is well absorbed, and while food may help decrease potential gastrointestinal upset, Plavix may be taken with or without food. Plavix is an antiplatelet agent used to prevent clot formation in clients who have experienced or are at risk for myocardial infarction, ischemic stroke, peripheral artery disease, or acute coronary syndrome.
A client is receiving Cilostazol (Pletal) for peripheral arterial disease causing intermittent claudication. The nurse determines this medication is effective when the client reports which of the following?
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Correct answer: D. "I am able to walk further without leg pain."
Cilostazol is indicated for management of intermittent claudication. Symptoms usually improve within 2 to 4 weeks of therapy. Intermittent claudication prevents clients from walking for long periods of time. Cilostazol inhibits platelet aggregation induced by various stimuli and improving blood flow to the muscles and allowing the client to walk long distances without pain. Peripheral arterial disease causes pain mainly of the leg muscles. "Aches and pains" does not specify exactly where the pain is occurring. Headaches may occur as a side effect of this drug, and the client should report this information to the health care provider. Peripheral arterial disease causes decreased blood supply to the peripheral tissues and may cause gangrene of the toes; the drug is effective when the toes are warm to the touch and the color of the toes is similar to the color of the body.
The client admitted with peripheral vascular 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:
Show answer and rationale
Correct answer: B. Decreased blood flow.
Decreased blood flow is a common characteristic of all PVD. When the demand for oxygen to the working muscles becomes greater than the supply, pain is the outcome. Slow blood flow throughout the circulatory system may suggest pump failure. Thrombus formation can result from stasis or damage to the intima of the vessels.
When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to:
Show answer and rationale
Correct answer: D. Increased venous pressure.
In PVD, decreased blood flow can result in increased venous pressure. The increase in venous pressure results in an increase in capillary hydrostatic pressure, which causes a net filtration of fluid out of the capillaries into the interstitial space, resulting in edema. Valves often become incompetent with PVD. Blood volume is not decreased in this condition. Decreased muscular action would contribute to the formation of edema in the lower extremities.
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?
Show answer and rationale
Correct answer: B. Age.
Age is a nonmodifiable risk factor for atherosclerosis. The nurse instructs the client to manage modifiable risk factors such as comorbid diseases (eg, diabetes), activity level, and diet. Controlling serum blood glucose levels, engaging in regular aerobic activity, and choosing a diet low in saturated fats can reduce the risk of developing atherosclerosis.
The nurse is assessing the lower extremities of the client with peripheral vascular disease (PVD). During the assessment, the nurse should expect to find which of the following clinical manifestations of PVD?
Show answer and rationale
Correct answer: B. Both of the above
Reduction of blood flow to a specific area results in decreased oxygen and nutrients. As a result, the skin may appear mottled. The skin will also be cool to the touch. Loss of hair and dry skin are other signs that the nurse may observe in a client with PVD of the lower extremities.
The nurse is unable to palpate the client’s left pedal pulses. Which of the following actions should the nurse take next?
Show answer and rationale
Correct answer: A. Use a Doppler ultrasound device.
When pedal pulses are not palpable, the nurse should obtain a Doppler ultrasound device. Auscultation is not likely to be helpful if the pulse isn’t palpable. Inspection of the lower extremity can be done simultaneously when palpating, but the nurse should first try to locate a pulse by Doppler. Calling the physician may be necessary if there is a change in the client’s condition.
Which of the following lipid abnormalities is a risk factor for the development of atherosclerosis and peripheral vascular disease?
Show answer and rationale
Correct answer: A. High levels of low-density lipid (LDL) cholesterol.
An increased LDL cholesterol concentration has been documented as a risk factor for the development of atherosclerosis. LDL cholesterol is not broken down in the liver but is deposited into the intima of the blood vessels. Low triglyceride levels are desirable. High HDL and low LDL levels are beneficial and are known to be protective for the cardiovascular system.
When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg?
Show answer and rationale
Correct answer: D. Coldness of the left foot and ankle.
Coldness in the left foot and ankle is consistent with complete arterial obstruction. Other expected findings would include paralysis and pallor. Aching pain, a burning sensation, or numbness and tingling are earlier signs of tissue hypoxia and ischemia and are commonly associated with incomplete obstruction.
The nurse is assessing an older Caucasian male who has a history of peripheral vascular disease. The nurse observes that the man’s left great toe is black. The discoloration is probably a result of:
Show answer and rationale
Correct answer: B. Gangrene.
The term gangrene refers to blackened, decomposing tissue that is devoid of circulation. Chronic ischemia and death of the tissue can lead to gangrene in the affected extremity. Injury, edema, and decreased circulation lead to infection, gangrene, and tissue death. Atrophy is the shrinking of tissue, and contraction is joint stiffening secondary to disuse. The term rubor denotes a reddish color of the skin.
A client has peripheral vascular disease (PVD) of the lower extremities. The client tells the nurse, "I’ve really tried to manage my condition well." Which of the following routines should the nurse evaluate as having been appropriate for this client?
Show answer and rationale
Correct answer: B. Walking slowly but steadily for 30 minutes twice a day.
Slow, steady walking is a recommended activity for clients with peripheral vascular disease because it stimulates the development of collateral circulation. The client with PVD should not remain inactive. Elevating the legs above the heart or wearing antiembolism stockings is a strategy for alleviating venous congestion and may worsen peripheral arterial disease.
A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by:
Show answer and rationale
Correct answer: A. Showing the location of the obstruction and the collateral circulation.
An arteriogram involves injecting a radiopaque contrast agent directly into the vascular system to visualize the vessels. It usually involves computed tomographic scanning. The velocity of the blood flow can be estimated by duplex ultrasound. The client’s ankle-brachial index is determined, and then the client is requested to walk. The normal response is little or no drop in ankle systolic pressure after exercise.
A client is scheduled to have an arteriogram. During the arteriogram, the client reports having nausea, tingling, and dyspnea. The nurse’s immediate action should be to:
Show answer and rationale
Correct answer: B. Inform the physician.
Clients may have an immediate or a delayed reaction to the radiopaque dye. The physician should be notified immediately because the symptoms suggest an allergic reaction. Treatment may involve administering oxygen and epinephrine. Explaining that the procedure is over does not address the current symptoms.
A client with peripheral vascular disease has chronic, severe pretibial and ankle edema bilaterally. Because the client is on complete bed rest and circulation is compromised, one goal is to maintain tissue integrity. Which of the following interventions will help achieve this outcome?
Show answer and rationale
Correct answer: D. Turning the client every 1 to 2 hours.
The client is at greater risk for skin breakdown in the lower extremities related to the edema and to remaining in one position, which increases capillary pressure. Turning the client every 1 to 2 hours promotes vasodilation and prevents vascular compression. Administering pain medication will not have an effect on skin integrity. Encouraging fluids is not a direct intervention for maintaining skin integrity, although being well hydrated is a goal for most clients. Maintaining hygiene does influence skin integrity but is secondary in this situation.
A client who has been diagnosed with peripheral vascular disease (PVD) is being discharged. The client needs further instruction if she says she will:
Show answer and rationale
Correct answer: B. Use iodine on an injured site.
The client should avoid using iodine or over-the-counter medications. Iodine is a highly toxic solution. An individual who has known PVD should be seen by a physician for treatment to avoid infection. The client with PVD should avoid heating pads and crossing the legs, and should wear leather shoes. A heating pad can cause injury, which, because of the decreased blood supply, can be difficult to heal. Crossing the legs can further impede blood flow. Leather shoes provide better protection.
A client with peripheral vascular disease has bypass surgery. The primary goal of the plan of care after surgery is to:
Show answer and rationale
Correct answer: B. Maintain circulation.
Maintaining circulation in the affected extremity after surgery is the focus of care. The graft can become occluded, and the client must be assessed frequently to determine whether the graft is patent. Preventing infection and relieving pain are important but are secondary to maintaining graft patency. Education should have taken place in the preoperative phase and then continued during the recovery phase.
The nurse is instructing a client who is at risk for peripheral vascular disease how to use knee-length elastic stockings (support hose). The teaching plan should include which of the following?
Show answer and rationale
Correct answer: A. Both of the above
Elastic stockings (support hose) are used to promote circulation by preventing pooling of blood in the feet and legs. The stockings should be applied in the morning before the client gets out of bed. The stockings should be applied smoothly to avoid wrinkles, but the top should not be rolled down to avoid constriction of circulation. The stockings should be removed every 8 hours and the client should elevate the legs for 15 minutes and reapply the stockings. Clean stockings should be applied daily or as needed.
A client is scheduled to undergo right axillary-to-axillary artery bypass surgery. Which of the following interventions is most important for the nurse to implement in the preoperative period?
Show answer and rationale
Correct answer: A. Avoid using the arm for a venipuncture.
If surgery is scheduled, the nurse should avoid venipunctures in the affected extremity. The goal should be to prevent unnecessary trauma and possible infection in the affected arm. Disruptions in skin integrity and even minor skin irritations can cause the surgery to be canceled. The nurse can continue to monitor the temperature and radial pulse in the affected arm; however, doing so is not the priority. Keeping the client warm is important but is not the priority at this time.
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 should encourage the client to:
Show answer and rationale
Correct answer: A. Stop smoking.
Nicotine causes vasospasm and impedes blood flow. Stopping smoking is the most significant lifestyle change the client can make. The client should eat low-fat foods as part of a balanced diet. The legs should not be elevated above the heart because this will impede arterial flow. The legs should be in a slightly dependent position. Jogging is not necessary and probably is not possible for many clients with arterial occlusive disease. A rehabilitation program that includes daily walking is suggested.
The client has aching, weakness, and a cramping sensation in both of the lower extremities while walking. To promote health and maintain the client’s level of activity, the nurse should suggest that the client try:
Show answer and rationale
Correct answer: C. Riding a stationary bike.
In this case, the exercise prescription needs to be individualized because walking causes discomfort. To maintain the level of activity and decrease venous congestion, riding a stationary bike is another appropriate exercise behavior. Use of a stationary bike provides a non-weight-bearing exercise modality, which allows a longer duration of activity. Jogging and crosscountry skiing are weight-bearing activities. In addition, crosscountry skiing involves a cold environment, and maintaining warmth is essential in promoting arterial blood flow and preventing vasoconstriction. Golfing is a good activity, but it is not typically considered an exercise that causes aerobic changes in the body.
The client with peripheral vascular disease has been prescribed diltiazem (Cardizem). The nurse should determine the effectiveness of this medication by assessing the client for:
Show answer and rationale
Correct answer: B. Vasodilation.
Diltiazem is a calcium channel blocker that blocks the influx of calcium into the cell. In this situation, the primary use of diltiazem is to promote vasodilation and prevent spasms of the arteries. As a result of the vasodilation, blood, oxygen, and nutrients can reach the muscle and tissues. Diltiazem is not an antianxiety agent and does not promote sedation. It also does not cause vasoconstriction, which would be contraindicated for the client with peripheral vascular disease.
A client is receiving pentoxifylline (Trental) for intermittent claudication. The nurse should determine the effectiveness of the drug by asking if the client:
Show answer and rationale
Correct answer: C. Has improved circulation in the legs.
Although pentoxifylline’s (Trental) precise mechanism of action is unknown, its therapeutic effect is to increase blood flow, and the client should have improved circulation in the legs. The client does not have nerve impairment and should be able to wiggle the toes. Urination is not improved by taking pentoxifylline. Dizziness is a side effect of the drug, not an intended outcome.
A client with peripheral vascular disease, coronary artery disease and chronic obstructive pulmonary disease takes theophylline 200 mg twice daily every day, and digoxin 0.5 mg once a day. The physician now prescribes pentoxifylline. To prevent problematic adverse effects, the nurse should monitor the client’s:
Show answer and rationale
Correct answer: A. Theophylline level.
Pentoxifylline can potentiate the effects of theophylline and increase the risk of theophylline toxicity. Therefore, the nurse should monitor the client’s theophylline level. Pentoxifylline does not interact with digoxin. Pentoxifylline can interact with heparin, and the client’s PTT would need to be monitored closely if the client were taking heparin. It does not affect cholesterol levels.
A client with a history of coronary artery disease (CAD) has been diagnosed with peripheral vascular disease. The physician started the client on pentoxifylline (Trental) once daily. Approximately 1 hour after receiving the initial dose of pentoxifylline, the client reports having chest pain. The nurse should first
Show answer and rationale
Correct answer: B. Contact the physician.
Angina is an adverse reaction to pentoxifylline, which should be used cautiously in clients with CAD. The nurse should report the client’s symptoms to the physician, who may prescribe nitroglycerin and possibly discontinue the pentoxifylline. The client should rest until the chest pain subsides, and documentation is essential when a client experiences an adverse reaction with medications that have been prescribed; however, the nurse’s top priority is to call the physician, report the problem, and obtain a prescription for nitroglycerin. The client’s reports of symptoms should never be dismissed.
A client with peripheral vascular disease is recovering from an aortofemoral-popliteal bypass graft. When developing a postoperative education plan, which question by the nurse will provide the most helpful information?
Show answer and rationale
Correct answer: B. "How did you manage your health before admission?"
Assessing the individual’s health behavior before surgery will help the nurse and client develop strategies to manage the postoperative course. Asking open-ended questions will elicit the most helpful information. The client’s ability to walk after surgery will be improved after surgery. The nurse can ask direct questions after obtaining general information.
The client with peripheral vascular disease and a history of hypertension is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which should be the nurse’s first step in planning the dietary instructions?
Show answer and rationale
Correct answer: A. Assess the family’s food preferences.
Before beginning dietary interventions, the nurse must assess the client’s pattern of food intake, life style, food preferences, and ethnic, cultural, and financial influences.
While the nurse is providing preoperative teaching for a client with peripheral vascular disease who is to have a below-the-knee amputation, the client says, "I hate the idea of being an invalid after they cut off my leg." The nurse’s most therapeutic response should be:
Show answer and rationale
Correct answer: A. "Tell me more about how you’re feeling."
Encouraging the client who is undergoing amputation to verbalize feelings is the most therapeutic nursing intervention. By eliciting concerns, the nurse may be able to provide information to help the client cope. The nurse should avoid value-laden responses, such as "You’ll still have one good leg," that may make the client feel guilty or hostile and block further communication. The nurse should not ignore the client’s expressed concerns, nor should the nurse reinforce the client’s concern about invalidism and dependency or assume that his wife is willing to care for him.
The client asks the nurse, "Why can’t the doctor tell me exactly how much of my leg they’re going to take off? Don’t you think I should know that?" The nurse responds, knowing that the final decision on the level of the amputation will depend primarily on:
Show answer and rationale
Correct answer: B. The adequacy of the blood supply to the tissues.
The level of amputation commonly cannot be accurately determined until surgery, when the surgeon can directly assess the adequacy of the circulation of the residual limb. A longer residual limb facilitates prosthesis fitting and will make it easier for the client to walk. However, although these aspects will be considered in the final decision, they are not the primary factors influencing the decision.
The nurse is monitoring a client after an above-the-knee amputation and notes that blood has saturated through the distal part of the dressing. The nurse should immediately:
Show answer and rationale
Correct answer: B. Assess vital signs.
The client should be evaluated for hemodynamic stability and extent of bleeding prior to calling the physician. Direct pressure can be used prior to applying a tourniquet if there is significant bleeding. To avoid flexion contractures, which can delay rehabilitation, elevation of the surgical limb is contraindicated.
Which of the following clients is at greatest risk for Buerger’s disease?
Show answer and rationale
Correct answer: D. A 29-year-old male with a 14-year history of cigarette smoking.
Thromboangiitis obliterans (Buerger’s disease) is a nonatherosclerotic, inflammatory vasoocclusive disorder. The disorder occurs predominantly in younger men less than 40 years of age and there is a very strong relationship with tobacco use. Diagnosis is based on age of onset, history of tobacco use, symptoms, and exclusion of diabetes mellitus.
The primary goal for the client with Buerger’s disease is to prevent:
Show answer and rationale
Correct answer: C. Thrombus formation.
Because of the inflammation, a common complication of Buerger’s disease is thrombus formation and potential occlusion of the vessel. Inflammation of the immediate and small arteries and veins is involved in the disease process. Embolus is a potential risk if a thrombus has developed. Fat embolus is associated with fractures of the bones. Thrombophlebitis occurs after thrombus formation.
A client with Buerger’s disease has established a goal to stop smoking. Which medication would be the most helpful in attaining this goal?
Show answer and rationale
Correct answer: A. Bupropion.
Bupropion is used to promote smoking cessation. All types of nicotine should be avoided to prevent vasoconstriction. Nitroglycerin, used for angina, and ibuprofen, an anti-inflammatory medication, have no role in smoking cessation.
The nurse is assessing a client with Buerger’s disease. The nurse should determine if the client is experiencing:
Show answer and rationale
Correct answer: B. Inflammation and fibrosis of arteries, veins, and nerves.
Buerger’s disease is characterized by inflammation and fibrosis of arteries, veins, and nerves. White blood cells infiltrate the area and become fibrotic, which results in occlusion of the vessels. Signs and symptoms include slowly developing claudication, cyanosis, coldness, and pain at rest. Thickening of the intima and media of the artery is characteristic of atherosclerosis. Vasospasm lasting several minutes is characteristic of Raynaud’s disease. Pain, pallor, and pulselessness are symptoms of acute occlusion of an artery by an embolus or other cause (eg, compartment syndrome).
When instructing a client who has been newly diagnosed with vasospastic disorder (Raynaud’s phenomenon) about management of care, the nurse should discuss which of the following topics?
Show answer and rationale
Correct answer: A. Benefit of an angioplasty to the affected extremities.
Clients with Raynaud’s phenomenon should receive routine follow-up to monitor symptoms and to assess for the development of connective tissue or autoimmune diseases associated with Raynaud’s. Beta blockers are not considered first-line drug therapy. A sympathectomy is considered only in advanced cases. There is no benefit to an angioplasty, which is used for atherosclerotic vascular disease.
A client has been diagnosed with vasospastic disorder (Raynaud’s phenomenon) on the tip of the nose and fingertips. The physician has prescribed reserpine (Serpasil) to determine if the client will obtain relief. The client often works outside in cold weather and also smokes two packs of cigarettes per day. Which of the following should be included in the discharge plan for this client?
Show answer and rationale
Correct answer: C. All of the above
Vasospastic disorder (Raynaud’s disease) is a form of intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of the fingertips, toes, or tip of the nose, and a rebound circulation with redness and pain. The nurse should instruct the client to stop smoking because nicotine is a vasoconstrictor. An adverse effect of reserpine is orthostatic hypotension. The client should report dizziness and low blood pressure as it may be necessary to consider stopping the drug. The client should prevent vasoconstriction by covering affected parts when in cold environments. The nurse can teach the client to rewarm exposed extremities by using warm water or placing them next to the body, such as under the axilla. It is not realistic to ask this client to change jobs at this time
Which of the following clients is at greatest risk for vasospastic disorder (Raynaud’s phenomenon)?
Show answer and rationale
Correct answer: B. Young women.
Vasospastic disorder (Raynaud’s disease) is more common in young women and is associated with collagen diseases such as rheumatoid arthritis and lupus.
The client with vasospastic disorder (Raynaud’s phenomenon) has coldness and numbness in the fingers. The nurse assesses the client for effects of vasoconstriction. Which of the following is an early sign of vasoconstriction?
Show answer and rationale
Correct answer: C. Pallor.
Initially, the vasoconstriction effect produces pallor or a whitish coloring, followed by cyanosis (bluish) and finally rubor (red). Gangrene is the end result of complete arterial occlusion; the skin is blackened and without a blood supply.
The nurse should instruct a client who has been diagnosed with vasospastic disorder (Raynaud’s phenomenon) to:
Show answer and rationale
Correct answer: A. Wear gloves when handling ice or frozen foods.
Extreme changes in temperature can precipitate a vasospastic episode and should be avoided by clients with vasospastic disorder (Raynaud’s disease). The client should be encouraged to wear gloves when handling frozen foods or ice. The client should immerse the involved extremity in warm water during an episode to promote vasodilation and relaxation of the small arteries that are in spasm. The client can help prevent vasospasm brought on by temperature changes by wearing warm clothes. Living in a cold climate will exacerbate the symptoms.
In order to prevent recurrent vasospastic episodes with Raynaud’s phenomenon, the nurse should instruct the client to:
Show answer and rationale
Correct answer: A. Wear gloves when obtaining food from the refrigerator.
Loose warm clothing should be worn to protect from the cold. Wearing gloves when handling cold objects will help prevent vasospasms. Vibrating equipment and typing contribute to vasospasm. Tobacco and caffeine should be avoided. Elevation will decrease arterial perfusion during vasospasms.
A client with Raynaud’s phenomenon is prescribed diltiazem (Cardizem). An expected outcome is:
Show answer and rationale
Correct answer: D. Reduced episodes of finger numbness.
Calcium channel blockers are first-line drug therapy for the treatment of vasospasms with Raynaud’s phenomenon when other therapies are ineffective. Cardizem relaxes smooth muscles and improves peripheral perfusion, therefore reducing finger numbness. Cardizem decreases heart rate and is used to treat atrial fibrillation, but these are not associated with Raynaud’s. When vasospasms are prevented, an accurate SpO2 can be measured in the affected extremity; however, SpO2 is a measurement of systemic oxygenation not influenced by Cardizem.
The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first:
Show answer and rationale
Correct answer: B. Stay with the client during the first 15 minutes of infusion.
The most likely time for a blood transfusion reaction to occur is during the first 15 minutes or first 50 mL of the infusion. If a blood transfusion reaction does occur, it is imperative to keep an established IV line so that medication can be administered to prevent or treat cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-gauge or larger needle; a peripherally inserted central catheter line is not recommended, in order to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer’s solution and should be infused with only normal saline solution.
A client with deep vein thrombosis suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first?
Show answer and rationale
Correct answer: A. Elevate the head of the bed 30 to 45 degrees.
Elevating the head of the bed facilitates breathing because the lungs are able to expand as the diaphragm descends. Coughing and deep breathing do not alleviate the symptoms of a pulmonary embolus, nor does lung auscultation. The physician must be kept informed of changes in a client’s status, but the priority in this case is alleviating the symptoms.
The nurse is caring for a client with acute arterial occlusion of the left lower extremity. To prevent further tissue damage, it is important for the nurse to observe for which of the following?
Show answer and rationale
Correct answer: C. Gradual or acute loss of sensory and motor function.
Acute arterial occlusion is a sudden interruption of blood flow. The interruption can be the result of complete or partial obstruction. Acute pain, loss of sensory and motor function, and a pale, mottled, numb extremity are the most dramatic and observable changes that indicate a life-threatening interruption of tissue perfusion. Blood pressure and heart rate changes may be associated with the acute pain episode. Metabolic acidosis is a complication of irreversible ischemia. Swelling may result but may also indicate venous stasis or arterial insufficiency.
A client with venous thrombus reports having pain in the legs. The nurse should first:
Show answer and rationale
Correct answer: D. Elevate the foot of the bed.
Venous stasis can increase pain. Therefore, proper positioning in bed with the foot of the bed elevated or when sitting up in a chair can help promote venous drainage, reduce swelling, and reduce the amount of pain the client might experience. Placing a pillow under the knees causes flexion of the joint, resulting in a dependent position of the lower leg and causing a decrease in blood flow. Fluids are encouraged to maintain normal fluid and electrolyte balance but do little to relieve pain. Therapeutic massage to the legs is discouraged because of the danger of breaking up the clot.
A 45-year-old client had a complete abdominal hysterectomy with bilateral salpingo-oophorectomy 2 days ago. The client’s abdominal dressing is dry and intact. The client is taking liquids and voiding a sufficient quantity of straw-colored urine. While sitting up in the chair, the client has severe pain and numbness in her left leg. The nurse should first:
Show answer and rationale
Correct answer: A. Assess color and temperature of the left leg.
The client is likely suffering from an embolus as a result of abdominal surgery. The nurse should inspect the left leg for color and temperature changes associated with tissue perfusion. Administering pain medication without gathering more information about the pain can mask important signs and symptoms. Although assessing for edema is important, it is not critical to this situation. Encouraging the client to change her position does not adequately address the need for gathering more data.
A client who is being discharged after a hospitalization for thrombophlebitis will be riding home in a car. During the 2-hour ride, the nurse should advise the client to:
Show answer and rationale
Correct answer: D. Perform ankle pumps and foot range-of-motion exercises.
Performing active ankle and foot range-of-motion exercises periodically during the ride home will promote muscular contraction and provide support to the venous system. It is the muscular action that facilitates return of the blood from the lower extremities, especially when in the dependent position. Arm circle exercises will not promote circulation in the leg. It is not necessary for the client to elevate the legs as long as the client does not occlude blood flow to the legs and does the leg exercises. It is not necessary to take an ambulance because the client is able to sit in the car safely.
A client is admitted with an acute onset of shortness of breath. A diagnosis of pulmonary embolism is made. One common cause of pulmonary embolism is:
Show answer and rationale
Correct answer: C. Deep vein thrombosis (DVT).
DVT is commonly associated with venous stasis in the legs when there is a lack of the skeletal muscle pump that enhances venous return to the heart. When a client is confined to bed rest, venous compression occurs because of the position of the lower extremities. This increased pressure causes damage to the intima lining of the veins and causes platelets to adhere to the damaged site. DVT increases the risk that a displaced plaque will become a pulmonary embolus. Arteriosclerosis is hardening of the arteries; aneurysm is the abnormal dilation of a vessel; and varicose veins are swollen, tortuous veins. These are not generally considered causes of pulmonary embolism.
In a postoperative client, the hematocrit decreased from 36% (0.36) to 34% (0.34) on the third day even though the red blood cell (RBC) count and hemoglobin value remained stable at 4.5 million/?L (4.5 � 1012/L) and 11.9 g/dL (119 g/L), respectively. The nurse should next:
Show answer and rationale
Correct answer: A. Continue to monitor vital signs.
The nurse should continue to monitor the client because this value reflects a normal physiologic response. The physician does not need to be called, and oxygen does not need to be started based on these laboratory findings. Immediately after surgery, the client’s hematocrit reflects a falsely high value related to the body’s compensatory response to the stress of sudden loss of fluids and blood. Activation of the intrinsic pathway and the renin-angiotensin cycle via antidiuretic hormone produces vasoconstriction and retention of fluid for the first 1 to 2 days postoperatively. By the second to third day, this response decreases and the client’s hematocrit level is more reflective of the amount of RBCs in the plasma. Fresh bleeding is a less likely occurrence on the third postoperative day but is not impossible; however, the nurse should have expected to see a decrease in the RBC count and hemoglobin value accompanying the hematocrit.
A client is on complete bed rest. The nurse should assess the client for risk for developing which of the following complications?
Show answer and rationale
Correct answer: D. Thrombophlebitis.
Thrombophlebitis is an inflammation of a vein. The underlying etiology involves stasis of blood, increased blood coagulability, and vessel wall injury. The symptoms of thrombophlebitis are pain, swelling, and deep muscle tenderness. Air embolus is a result of air entering the vascular system. Fat embolus is associated with the presence of intracellular fat globules in the lung parenchyma and peripheral circulation after long-bone fractures. Stress fractures are associated with the musculoskeletal system.
Knee-high sequential compression devices have been prescribed for a newly admitted client. The client reports new pain localized in the right calf area that is noted to be slightly reddened and warm to touch upon initial assessment. The nurse should first:
Show answer and rationale
Correct answer: A. Leave the compression devices off and contact the physician to report the assessment findings.
Localized pain, tenderness, redness, and warmth may be symptoms of deep vein thrombosis (DVT), information the nurse should report to the physician; the compression devices should not be applied until further evaluation is completed as intermittent compression may dislodge a thrombus. Massaging the area may dislodge a thrombus and is not recommended. The nurse may offer PRN analgesics if the client requires pain management, but the compression devices should not be applied until further evaluation is completed. Diagnosis and treatment of DVT should be discussed with the physician as soon as possible; the nurse should not wait until the next shift to report findings as a DVT can become life threatening if a thrombus travels to the lung and becomes a pulmonary embolus.
A client is receiving an IV infusion of 5% dextrose in water (D5W). The skin around the IV insertion site is red, warm to touch, and painful. The nurse should first:
Show answer and rationale
Correct answer: B. Discontinue the IV.
The first action should be to discontinue the IV. The nurse should restart the IV elsewhere and then apply a warm compress to the affected area. The nurse should administer acetaminophen or an anti-inflammatory agent only if prescribed by the physician. The type of infusion cannot be changed without a physician’s prescription, and such a change would not help in this case
The nurse is planning care for a client on complete bed rest. The plan of care should include all except which of the following:
Show answer and rationale
Correct answer: A. Maintaining the client in the supine position.
Three factors contribute to the formation of venous thrombus and thrombophlebitis: damage to the inner lining of the vein (prolonged pressure), hypercoagulability of the blood, and venous stasis. Bed rest and immobilization are associated with decreased blood flow and venous pooling in the lower extremities. Keeping the client in the supine position would not be appropriate. Turning the client every 1 to 2 hours, passive and active range-of-motion exercises, and use of TED hose help prevent venous stasis in the lower extremities.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
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