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Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)

Chapter 33: Concepts of Care for Patients With Vascular Problems Ignatavicius: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A nurse is assessing the peripheral vascular system of an older adult. What action by the nurse

would cause the supervising nurse to intervene? Assessing blood pressure in both upper extremities Auscultating the carotid arteries for any bruits Classifying capillary filling of 4 seconds as normal Palpating both carotid arteries at the same time

a. b. c. d.

ANS: D

The nurse would not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure would be taken and compared in both arms. Prolonged capillary filling is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits would be auscultated. DIF: TOP: KEY: MSC:

Remembering Integrated Process: Communication and Documentation Vascular system, Nursing assessment Client Needs Category: Physiological Integrity: Reduction of Risk Potential

2. The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel.

What meal selection indicates that the client is managing this condition well with diet? A 4-ounce steak, French fries, iceberg lettuce Baked chicken breast, broccoli, tomatoes Fried catfish, cornbread, peas Spaghetti with meat sauce, garlic bread

a. b. c. d.

ANS: B

The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is the chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables. DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Nutrition, Self-care MSC: Client Needs Category: Health Promotion and Maintenance 3. A nurse is working with a client who takes clopidogrel. The client’s recent laboratory results

include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best? a. Ask if the client eats grapefruit. b. Assess the client for dehydration. c. Facilitate admission to the hospital. d. Obtain a random urinalysis. ANS: A

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)

There is a drug–food interaction between clopidogrel and grapefruit that can lead to acute kidney failure. This client has elevated renal laboratory results, indicating some degree of kidney involvement. The nurse would assess if the client eats grapefruit or drinks grapefruit juice. Dehydration can cause the BUN to be elevated, but the elevation in creatinine is more specific for a kidney injury. The client does not necessarily need to be admitted. A urinalysis may or may not be ordered. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Medication-food interactions, Laboratory values MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A client has been diagnosed with hypertension but does not take the antihypertensive

medications because of a lack of symptoms. What response by the nurse is best? “Do you have trouble affording your medications?” “Most people with hypertension do not have symptoms.” “You are lucky; most people get severe morning headaches.” “You need to take your medicine or you will get kidney failure.”

a. b. c. d.

ANS: B

Most people with hypertension are asymptomatic, although a small percentage do have symptoms such as headache. The nurse would explain this to the client. Asking about paying for medications utilizes closed-ended questioning and is not therapeutic. Threatening the client with possible complications will not increase compliance. DIF: TOP: KEY: MSC:

Understanding Integrated Process: Communication and Documentation Hypertension, Medication adherence Client Needs Category: Physiological Integrity: Physiological Adaptation

5. A client asks what “essential hypertension” is. What response by the registered nurse is best? a. “It means it is caused by another disease.” b. “It means it is ‘essential’ that it be treated.” c. “It is hypertension with no specific cause.” d. “It refers to severe and life-threatening hypertension.” ANS: C

Essential hypertension is the most common type of hypertension and has no specific cause such as an underlying disease process. Hypertension that is due to another disease process is called secondary hypertension. A severe, life-threatening form of hypertension is malignant hypertension. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Hypertension, Pathophysiology MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A nurse is interested in providing community education and screening on hypertension. In

order to reach a priority population, to what target audience would the nurse provide this service? a. African-American churches b. Asian-American groceries c. High school sports camps

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files) d. Women’s health clinics ANS: A

African Americans in the United States have one of the highest rates of hypertension in the world. The nurse has the potential to reach this priority population by providing services at African-American churches. Although hypertension education and screening are important for all groups, African Americans are the priority population for this intervention. DIF: Remembering TOP: Integrated Process: Nursing Process: Analysis KEY: Hypertension, Primary prevention MSC: Client Needs Category: Health Promotion and Maintenance 7. A client has hypertension and high risk factors for cardiovascular disease. The client is

overwhelmed with the recommended lifestyle changes. What action by the nurse is best? a. Assess the client’s support system. b. Assist in finding one change the client can control. c. Determine what stressors the client faces in daily life. d. Inquire about delegating some of the client’s obligations. ANS: B

All options are appropriate when assessing stress and responses to stress. However, this client feels overwhelmed by the suggested lifestyle changes. Instead of looking at all the needed changes, the nurse would assist the client in choosing one the client feels optimistic about controlling. Once the client has mastered that change, he or she can move forward with another change. Determining support systems, daily stressors, and delegation opportunities does not directly impact the client’s feelings of control. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Hypertension, Psychosocial response MSC: Client Needs Category: Psychosocial Integrity 8. The nurse is caring for four hypertensive clients. Which drug–laboratory value combination

would the nurse report immediately to the health care provider? Furosemide/potassium: 2.1 mEq/L Hydrochlorothiazide/potassium: 4.2 mEq/L Spironolactone/potassium: 5.1 mEq/L Torsemide/sodium: 142 mEq/L

a. b. c. d.

ANS: A

Furosemide is a loop diuretic and can cause hypokalemia. A potassium level of 2.1 mEq/L is quite low and would be reported immediately. Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia. A potassium level of 5.1 mEq/L is on the high side, but it is not as critical as the low potassium with furosemide. The other two laboratory values are normal. DIF: Applying TOP: Integrated Process: Nursing Process: Analysis MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 9. A nurse is assessing a client with peripheral artery disease (PAD). The client states that

walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a. “Could you walk further than that a few months ago?” b. “Do you walk mostly uphill, downhill, or on flat surfaces?”

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files) c. “Have you ever considered swimming instead of walking?” d. “How much pain medication do you take each day?” ANS: A

As PAD progresses, it takes less oxygen demand to cause pain. Needing to cut down on activity to be pain free indicates that the client’s disease is worsening. The other questions are useful, but not as important. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Peripheral artery disease, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation 10. An older client with peripheral vascular disease (PVD) is explaining the daily foot care

regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. “I nearly always wear comfy sweatpants and house shoes.” b. “I’m glad I get energy assistance so my house isn’t so cold.” c. “My daughter makes sure I have plenty of lotion for my feet.” d. “My hands shake when I try to do things requiring coordination.” ANS: D

Clients with PVD need to pay special attention to their feet. Toenails need to be kept short and cut straight across. The client whose hands shake may cause injury when trimming toenails. The nurse would refer this client to a podiatrist. Comfy sweatpants and house shoes are generally loose and not restrictive, which is important for clients with PVD. Keeping the house at a comfortable temperature makes it less likely the client will use alternative heat sources, such as heating pads, to stay warm. The client should keep the feet moist and soft with lotion. DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Peripheral vascular disease, Home safety MSC: Client Needs Category: Health Promotion and Maintenance 11. A client is taking warfarin and asks the nurse if taking St. John’s wort is acceptable. What

response by the nurse is best? a. “No, it may interfere with the warfarin.” b. “There isn’t any information about that.” c. “Why would you want to take that?” d. “Yes, it is a good supplement for you.” ANS: A

Many foods and drugs interfere with warfarin, St. John’s wort being one of them. The nurse would advise the client against taking it. The other answers are not accurate. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Anticoagulants, Medication-food interactions MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 12. A nurse is teaching a female client about alcohol intake and how it affects hypertension. The

client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? a. “No, women should only have one beer a day as a general rule.”

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files) b. “No, you should not drink any alcohol with hypertension.” c. “Yes, since you are larger, you can have more alcohol.” d. “Yes, two beers per day is an acceptable amount of alcohol.” ANS: A

Alcohol intake should be limited to two drinks a day for men and one drink a day for women. A “drink” is classified as one beer, 1.5 ounces of hard liquor, or 5 ounces of wine. Limited alcohol intake is acceptable with hypertension. The woman’s size does not matter. DIF: Understanding TOP: Integrated Process: Teaching/Learning KEY: Hypertension, Lifestyle choices MSC: Client Needs Category: Health Promotion and Maintenance 13. A nurse is caring for four clients. Which one would the nurse see first? a. Client who needs a beta blocker, and has a blood pressure of 98/58 mm Hg. b. Client who had a first dose of captopril and needs to use the bathroom. c. Hypertensive client with a blood pressure of 188/92 mm Hg. d. Client who needs pain medication prior to a dressing change of a surgical wound. ANS: B

Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension, especially after the first dose. The nurse would see this client first to prevent falling if the client decides to get up without assistance. The two blood pressure readings are abnormal but not critical. The nurse would check on the client with higher blood pressure next to assess for problems related to the reading. The nurse can administer the beta blocker as standards state to hold it if the systolic blood pressure is below 90 to 100 mm Hg. The client who needs pain medication prior to the dressing change is not a priority over client safety and assisting the other client to the bathroom. DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis KEY: Hypertension, Angiotensin-converting enzyme (ACE) inhibitors MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 14. A client had a percutaneous angioplasty for renovascular hypertension 3 months ago. What

assessment finding by the nurse indicates that an important outcome for this client has been met? a. Client is able to decrease blood pressure medications. b. Insertion site has healed without redness or tenderness. c. Most recent lab data show BUN: 19 mg/dL and creatinine 1.1 mg/dL. d. Verbalizes understanding of postprocedure lifestyle changes. ANS: A

Hypertension can be caused by renovascular disease. Opening up a constricted renal artery can lead to decreased blood pressure, manifested by the need for less blood pressure medication. The other findings are normal and desired, but not specifically related to hypertension caused by renal disease. DIF: Analyzing TOP: Integrated Process: Nursing Process: Evaluation KEY: Hypertension, Perfusion MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files) 15. A client is 4 hours postoperative after a femoral-popliteal bypass. The client reports throbbing

leg pain on the affected side, rated as 7/10. What action by the nurse is most important? a. Administer pain medication as ordered. b. Assess distal pulses and skin color. c. Document the findings in the client’s chart. d. Notify the surgeon immediately. ANS: B

Once perfusion has been restored or improved to an extremity, clients can often feel a throbbing pain due to the increased blood flow. However, it is important to differentiate this pain from ischemia. The nurse would assess for other signs of perfusion, such as distal pulses and skin color/temperature. Administering pain medication is done once the nurse determines that the client’s perfusion status is normal. Documentation needs to be thorough. Notifying the surgeon is not necessary. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Peripheral vascular disease, Nursing process assessment MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care 16. A client had a femoral-popliteal bypass graft with a synthetic graft. What action by the nurse

is most important to prevent wound infection? a. Appropriate hand hygiene before giving care b. Assessing the client’s temperature every 4 hours c. Clean technique when changing dressings d. Monitoring the client’s daily white blood cell count ANS: A

Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing changes would be done with sterile technique. Assessing vital signs and white blood cell count will not prevent infection. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Infection control, Hand hygiene MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 17. A client is receiving an infusion of alteplase for an intra-arterial clot. The client begins to

mumble and is disoriented. What action by the nurse is most important? Assess the client’s neurologic status. Notify the Rapid Response Team. Prepare to administer vitamin K. Turn down the infusion rate.

a. b. c. d.

ANS: B

Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of neurologic signs may indicate that the client is having a hemorrhagic stroke. The nurse does need to complete a thorough neurologic examination, but would first call the Rapid Response Team based on the client’s manifestations. Vitamin K is not the antidote for this drug. Turning down the infusion rate will not be helpful if the client is still receiving any of the drug. DIF: Applying TOP: Integrated Process: Nursing Process: Implementation KEY: Critical rescue, Fibrinolytic agents MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)

18. A new nurse is caring for a client with an abdominal aneurysm. What action by the new nurse

requires the nurse’s mentor to intervene? a. Assesses the client for back pain. b. Auscultates over abdominal bruit. c. Measures the abdominal girth. d. Palpates the abdomen in four quadrants. ANS: D

Abdominal aneurysms should never be palpated as this increases the risk of rupture. The nurse mentoring the new nurse would intervene when the new nurse attempts to do this. The other actions are appropriate. DIF: Applying TOP: Integrated Process: Communication and Documentation KEY: Aneurysms, Abdominal assessment MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 19. A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment

indicates that an important outcome has been met? Ambulates with assistance Oxygen saturation of 98% Pain of 2/10 after medication Verbalizing risk factors

a. b. c. d.

ANS: B

A critical complication of DVT is pulmonary embolism. A normal oxygen saturation indicates that this has not occurred. The other assessments are also positive, but not as important. DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment KEY: Pulmonary embolism, Nursing assessment MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 20. A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to

the assistive personnel (AP)? Ambulate the client. Apply a warm moist pack. Massage the client’s leg. Provide an ice pack.

a. b. c. d.

ANS: B

Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort measure. Massaging the client’s legs is contraindicated to prevent complications such as pulmonary embolism. Ice packs are not recommended for DVT. DIF: TOP: KEY: MSC:

Understanding Integrated Process: Communication and Documentation Thromboembolic event, Comfort measures Client Needs Category: Physiological Integrity: Basic Care and Comfort

21. A nurse is assessing an obese client in the clinic for follow-up after an episode of deep vein

thrombosis. The client has lost 20 lb (9.09 Kg) since the last visit. What action by the nurse is best?

Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files) a. b. c. d.

Ask if the weight loss was intended. Encourage a high-protein, high-fiber diet. Measure for new compression stockings. Review a 3-day food recall diary.

ANS: C

Compression stockings must fit correctly in order to work. After losing a significant amount of weight, the client would be remeasured and new stockings ordered if needed. The other options are appropriate, but not the most important. DIF: Applying TOP: Integrated Process: Nursing Process: Assessment KEY: Thromboembolic event, Nursing assessment M...