Deck 27: Vascular Dysfunction: Nursing Management

Question 1

The nurse is concerned that an elderly client has evidence of arteriosclerosis since the client's capillary refill is greater than:

A) 3 seconds.
B) 4 seconds.
C) 5 seconds.
D) 6 seconds.

Answer 1

5 seconds.

Question 2

The nurse is assessing a client diagnosed with an abdominal aortic aneurysm. Which of the following sounds did the nurse auscultate during the assessment?

A) Pleural rub
B) Hyperactive bowel sounds
C) Crackles
D) Bruit

Answer 2

Bruit

Question 3

A client's blood pressure measurements have a 20 mmHg difference between the upper extremity readings. Which of the following does this assessment finding suggest to the nurse?

A) Arteriosclerosis
B) Aortic aneurysm
C) Deep vein thrombosis
D) Subclavian steal syndrome

Answer 3

Subclavian steal syndrome

Question 4

A client receiving a heparin infusion is demonstrating signs of acute bleeding. Which of the following should the nurse prepare to administer to this client?

A) Aspirin
B) Vitamin K
C) Protamine sulfate
D) Narcan

Question 5

A client is diagnosed with acute peripheral arterial occlusion. The nurse should prepare to provide which of the following interventions for this client?

A) Administer oxygen.
B) Assist with ambulation.
C) Administer heparin as prescribed.
D) Restrict fluids.

Question 6

A client diagnosed with arteriosclerosis is prescribed an anticoagulant. For which of the following should the nurse assess in this client?

A) Respiratory distress
B) Skin breakdown
C) Decreased urine output
D) Bruising and bleeding

Question 7

The nurse is utilizing the Wells Scale to assess a client for deep vein thrombosis. Which of the following is assessed when using this scale? (Select all that apply.)

A) Treatment for cancer
B) Recent immobility for greater than 3 days
C) Recovery from surgery with general anesthesia within 12 weeks
D) Entire leg edematous
E) Pitting edema of the symptomatic leg
F) Blood pressure 130/86 mmHg

Question 8

The nurse is instructing a client recovering from arterial aneurysm repair. Which of the following should be included in these instructions? (Select all that apply.)

A) Do not lift anything heavier than 15 to 20 lbs.
B) Limit activity for up to 8 weeks after the surgery.
C) Use a pillow to splint when coughing.
D) Driving is permitted 1 week after surgery.
E) Notify the physician for pain, redness, or swelling around the incision.
F) Avoid pain medication.

Question 9

A client is diagnosed with a venous stasis ulcer on the foot. Which of the following will be included in this client's plan of care? (Select all that apply.)

A) Administer oral antibiotics if infection is present.
B) Keep the foot open to the air.
C) Cover the foot with a hydrocolloidal dressing.
D) Provide pain medication with debridement.
E) Restrict fluids.
F) Instruct the client to ambulate without shoes.

Question 10

The nurse is assessing a client diagnosed with a peripheral arterial occlusion. Which of the following will the nurse assess in this client? (Select all that apply.)

A) Pulselessness
B) Pain
C) Pallor
D) Paresthesia
E) Paralysis
F) Petechiae

Question 11

Which of the following should the nurse instruct a client in order to reduce the risk factors for developing arteriosclerosis?

A) Limit diet to contain less than 40% fat
B) Restrict exercise
C) Stop smoking
D) Avoid prescription medications

Question 12

A client who has experienced signs of Virchow's triad has developed a deep vein thrombosis. Which of the following is not a part of this triad?

A) Venous stasis
B) Vessel wall injury
C) Alteration in blood clotting
D) Pregnancy

Question 13

A client is diagnosed with Buerger's disease. Which of the following should the nurse instruct the client regarding this disorder?

A) It is a common disorder.
B) It appears in women more than in men.
C) Smoking exacerbates the disease.
D) It is more common in African Americans.

Question 14

A client is diagnosed with Raynaud's disease. Which of the following will the nurse most likely assess in this client?

A) Elevated blood pressure
B) Pain, cyanosis, and numb, cold extremities
C) Absent peripheral pulses
D) Increase in varicose veins

Question 15

When instructing a client on ways to lower his cholesterol levels, which of the following should the nurse include?

A) Eat more meat and eggs.
B) Consume less meat and eggs.
C) Incorporate more vegetables.
D) Limit fruits.

Question 16

The nurse is assessing a client for risks in the development of varicose veins. Which of the following findings would increase this client's risk?

A) Normal weight
B) Prolonged standing
C) Engages in golf three times a week
D) Eats several servings of fruits and vegetables each day

Question 17

A client is admitted with abdominal aortic aneurysm. For which of the following complications should the nurse be concerned?

A) Hypotension
B) Cardiac arrhythmias
C) Aneurysm rupture
D) Loss of bowel sounds