Question 1

The nurse is planning the care for a patient who is to have a saphenous vein stripping.What will be the priority intervention?

Accepted Answer

Bed rest with leg elevation the first night after surgery is the standard of care.The legs are wrapped with Ace bandages to prevent hematomas and stimulate sluggish circulation.There is only minimal discomfort.Legs should not be massaged in any patient undergoing vein stripping.

Question 2

An 86-year-old patient asks why her ankles have a brownish discoloration and the skin looks so thick.Which is the most accurate response by the nurse?

Accepted Answer

Hemosiderin leaks out of the trapped red blood cells in the dilated vessels of the feet and ankles and stains the skin of people with venous insufficiency.In addition,fibrous tissue replaces subcutaneous tissue around the ankles and causes the skin to become thick and hardened.Iron and nicotine do not play a role in these skin changes with venous insufficiency,and these are not normal changes associated with aging.

Question 3

The 75-year-old diabetic patient has an inflamed area at the shin caused by scratching.Which intervention should the nurse perform first?

Accepted Answer

Covering the area with a clear dressing protects the area from further scratching and becoming infected.The skin break should be recorded and the primary care provider notified of the area and the immediate action taken.The nurse cannot apply antibiotic ointment or an ACE bandage without an order,and neither of these interventions is warranted in this situation.

Question 4

The Unna paste boot is wrapped in a variety of directions to make the most of muscular action.These dressings are usually changed:

Accepted Answer

Compression dressings are changed every 2 to 3 days.

Question 5

The nurse is initiating the care plan for a patient with peripheral arterial disease,who complains of pain in the lower extremities at a 3/10,has a 0.5 cm ´ 1 cm ulcer on the left lower leg,and the lower legs are shiny and hairless bilaterally.What is the priority nursing diagnosis?

Accepted Answer

Impaired skin integrity is the priority diagnosis in this situation.Acute pain is a nursing diagnosis,but the pain is 3/10 so it is not the priority since there is an open wound.Injury and deficient knowledge could be problems,but there is not enough information to support these diagnoses.

Question 6

Hypertension is diagnosed by the finding of a blood pressure reading greater than:

Accepted Answer

A diagnosis of hypertension is made if the systolic pressure is equal to or greater than 140 mm Hg and the diastolic pressure is equal to or greater than 90 mm Hg at least twice on two different occasions 2 weeks apart.

Question 7

The nurse is providing patient teaching to a pregnant patient who works as a cashier in a grocery store.Which suggestion by the nurse will help most in preventing varicose veins?

Accepted Answer

Marching in place or any leg exercises will help blood flow in the lower limbs and prevent varicose veins.Support hose are very beneficial.Supportive shoes and vitamin C do not prevent venous congestion.

Question 8

The patient scheduled for a percutaneous angioplasty (PTA)is instructed that a ________ is left in the artery to keep it patent.

Accepted Answer

A stent is left in the vessel after the angioplasty to keep the vessel open.

Question 9

The home health nurse is alarmed that the hypertensive patient's blood pressure has risen to 200/160,but he denies any discomfort.The nurse interprets these assessments as being indicative of:

Accepted Answer

The diastolic pressure rising to readings between 140 and 170 and the patient being asymptomatic indicate malignant hypertension.

Question 10

The nurse cautions the patient with uncontrolled hypertension that the consequences of the disease will include: (Select all that apply.)

Accepted Answer

DVT is not usually the result of hypertension.All other options are possible complications of uncontrolled hypertension.

Question 11

The patient has been prescribed a low-sodium diet.Which food omissions from the diet will indicate the patient has an adequate understanding of the recommended diet?

Accepted Answer

Hot dogs and all other processed meats contain large amounts of sodium.Fresh fruits,vegetables,and pasta are allowed on a low-sodium diet.

Question 12

The student nurse is planning a presentation on hypertension to present in a community setting.Which group of individuals should the student identify as having the highest incidence of hypertension?

Accepted Answer

African Americans have a higher incidence of hypertension than any other minority group or whites.

Question 13

The patient with a deep venous thrombosis is on a protocol of IV urokinase.The nurse clarifies that this drug will:

Accepted Answer

Urokinase is given IV to dissolve the clot.The patient is very carefully monitored for bleeding.

Question 14

The patient is instructed that the most common and effective antiplatelet aggregation agent is:

Accepted Answer

Aspirin is the most common and effective antiplatelet agent.

Question 15

The nurse is caring for a patient diagnosed with an abdominal aortic aneurysm.The patient is complaining of intense abdominal pain and lightheadedness.The patient's blood pressure has dropped and pulse is rising.What is the priority nursing intervention?

Accepted Answer

The patient is most likely experiencing a ruptured aneurysm,which is a medical emergency requiring surgical repair;therefore,the physician should be contacted immediately.The vital signs may need to be measured more often than every 15 minutes.Notifying the family is not the priority intervention.Ongoing assessment of pain should continue.

Question 16

Peripheral vascular disease (PVD)is characterized by: (Select all that apply.)

Accepted Answer

PVD usually only involves the lower extremities.All other options are the symptoms of PVD.

Question 17

The nurse assessing a patient with a deep venous thrombosis (DVT)becomes concerned when the patient demonstrates which sign or symptom?

Accepted Answer

Development of embolisms are of primary concern for the patient with a DVT.Coughing of rust-colored sputum is the cardinal sign of a pulmonary embolus,which is a medical emergency.

Question 18

Because of reduced sensitivity of the baroreceptors in the older adult who is also on a diuretic,the nurse instructs the patient to:

Accepted Answer

Reduced sensitivity of the baroreceptors along with taking a diuretic predisposes the older adult to orthostatic hypotension;therefore,the nurse should caution the patient to change postures slowly to prevent becoming faint and falling.

Question 19

The patient who is on daily doses of warfarin is instructed in the use of a coagulation monitoring device.The patient is taught that the device will monitor which blood clotting time?

Accepted Answer

A coagulation monitoring device measures the INR level for clotting time for a person on therapeutic doses of warfarin.

Question 20

The nurse adds an intervention to the care plan of a patient who has just been prescribed a thiazide diuretic,which is to increase:

Accepted Answer

The thiazide diuretics are potent diuretics that flush out water,sodium,and potassium quickly.Potassium should be replaced,if not by prescription of oral potassium salts,then by modifying the diet.

Quiz 19: Care of Patients With Hypertension and Peripheral Vascular Disease