AND ANSWERS RATED A+
✔✔Which instruction is a key aspect of teaching for the patient on anticoagulant
therapy?
A. Monitor for and report any signs of bleeding
B. Do not take Tylenol for a headache
C. Decrease your dietary intake for foods containing vitamin K
D. Arrange to have blood drawn twice a week to check drug effects - ✔✔a. Monitor for
and report any signs of bleeding.
✔✔The nurse is planning care and teaching for a patient with venous leg ulcers. What is
the most important patient action in healing and control of this condition?
A. Following activity guidelines
B. Using moist environmental dressings
C. Taking horse chestnut seed extract daily
D. Applying graduated compression stockings - ✔✔D. Applying graduated compression
stockings
✔✔Assessment findings suggestive of peritonitis include (select all that apply)
a. rebound abdominal pain
b. a soft, distended abdomen
c. dull, continuous abdominal pain
d. observing that the patient is restless
e. shallow respirations with bradypnea - ✔✔a. rebound abdominal pain
d. observing that the patient is lying still
Rationale: With peritoneal irritation, the abdomen is hard, like a board, and the patient
has severe abdominal pain that is worse with any sudden movement. The patient lies
very still. Palpating the abdomen and releasing the hands suddenly causes sudden
movement within the abdomen and severe pain. This is called rebound tenderness.
✔✔Which assessment finding is considered a classic manifestation in lower extremity
PAD?
A. Rest pain
B. Skin ulcerations
C. Intermittent claudication
D. Paresthesia in the feet and bones - ✔✔C. Intermittent claudication
✔✔The nurse provides care for a patient one day after the patient underwent peripheral
artery bypass surgery. Which intervention will the nurse include in the patient's care?
A. Maintain patient bed rest
B. Assist the patient with walking several times
C. Encourage the patient to sit in the chair several times
D. Place the patient in a side-lying position with the knees flexed. - ✔✔B. Assist the
patient with walking several times
,✔✔The nurse is assessing a patient with lower extremity PAD. Which clinical
manifestation would the nurse expect to find.
A. Presence of peripheral pulses
B. Heaviness in the calf or thigh
C. Loss of hair on legs, feet, and toes
D. Presence of edema in the lower leg - ✔✔C. Loss of hair on legs, feet, and toes
✔✔A male Hispanic patient is diagnosed with PAD. The patient's health history includes
smoking and depression. Which risk factor does this patient have for PAD?
A. Gender
B. Tobacco
C. Ethnicity
D. Comorbidity - ✔✔B. Tobacco
✔✔A patient reports gastric distress that occurs to to five hours after meals, with
"burning" and "cramping" pain just below the xiphoid process. Which disorder would the
nurse suspect that the patient may have?
A. Esophagitis
B. Gastric ulcer
C. Bacterial peritonitis
D. Chronic gastritis - ✔✔C. Bacterial peritonitis
✔✔Which symptom would the nurse expect in a patient who has a gastric ulcer
perforation?
A. Pyrosis
B. Rigid abdomen
C. Bright-red emesis
D. Clay-colored stools - ✔✔B. Rigid abdomen
✔✔A patient receives a prescription for 60 mg enoxaparin. Which injection site would
the nurse use to administer the medication safely?
A. Flank
B. Thigh
C. Deltoid
D. Abdomen - ✔✔D. Abdomen
✔✔The health care provider prescribes warfarin for a patient VTE. Which information
would the nurse include in the patient's discharge teaching plan?
A. No routine laboratory monitoring is needed
B. Avoid contact sports and high risk activities
C. Increase daily intake of dark-green, leafy vegetables.
D. Continue to use garlic as a dietary supplement. - ✔✔B. Avoid contact sports and high
risk activities
,✔✔A patient presents with symptoms of VTE in the calf. Which study would the nurse
expect to be prescribed to investigate for VTE?
A. Duplex ultrasound
B. Contrast venography
C. Magnetic resonance venography
D. Computed tomography venography - ✔✔A. Duplex ultrasound
✔✔The nurse is performing a physical assessment on a patient with CVI. Which
manifestation involving the lower extremities would the nurse expect?
A. Shiny skin
B. Absent pulses
C. Brownish color
D. Lack of sensation - ✔✔C. Brownish color
✔✔Which intervention would the nurse include in the care of a patient who has CVI?
A. Application of topical antibiotics to venous ulcers
B. Administering oral or subcutaneous anticoagulants
C. Maintaining the patient's legs in a dependent position
D. Teaching the patient the correct use of compression stockings - ✔✔D. Teaching the
patient the correct use of compression stockings
✔✔A patient with acute gastritis has an NG tube to low-intermittent suction with bilious
drainage. Later the nurse observes that the drainage is blood-tinged. What action would
the nurse take next?
A. Assess the patient's pain
B. Obtain a set of vital signs
C. Page the health care provider
D. Document the data in the patient's record - ✔✔B. Obtain a set of vital signs
✔✔The nurse notes that a patient who had a total gastrectomy the day before has a
very small amount of fluid draining from the NG tube. Which action would the nurse
take?
A. Increase the power on the suction device
B. Irrigate the NG tube with 50 mL of sterile saline
C. Continue to monitor the patient and the drainage
D. Notify the health care provider immediately. - ✔✔C. Continue to monitor the patient
and the drainage
✔✔The nurse provides post-op care 8 hours after a patient underwent a laparotomy.
The nurse assesses the drainage rom the nasogastric tube and notifies the health care
provider immediately about which finding?
A. Bright red drainage
B. Bright green drainage
C. Dark-brown drainage
D. Dark-red drainage - ✔✔A. Bright red drainage
, ✔✔After the patient has undergone an esophagogastroduodenoscopy (EGD), which is
the nursing priority.
A. Provide warm saline gargles for relief of sore throat
B. Assess the patient's bowel sounds
C. Keep the patient NPO until the gag reflex returns
D. Address the patient's anxieties about the results of the EGD - ✔✔C. Keep the patient
NPO until the gag reflex returns
✔✔The nurse provides postoperative care to a patient who underwent peripheral artery
bypass surgery. Thirty minutes after the initial assessment, the nurse reassesses the
patient and detects a change in the Doppler sound over a pulse. What action should the
nurse take?
A. Contact the health care provider
B. Administer an oral anticoagulant
C. Measure the ankle-brachial index
D. Recheck the pulse in another 30 minutes - ✔✔A. Contact the health care provider
✔✔A patient who has undergone peripheral artery bypass surgery report increased pain
and tingling in the extremities. The nurse notes the loss of a previously palpable pulse
and cyanosis. Which condition is consistent with these findings?
A. Blockage of the graft
B. Compartment syndrome
C. Thoracic aortic aneurysms
D. Superficial vein thrombosis - ✔✔A. Blockage of the graft
✔✔A patient who is admitted to the hospital with a duodenal ulcer develops signs of
acute duodenal perforation. Which action would the nurse expect to take first.
A. Administer an H2 blocker
B. Administer pain medication
C. Insert an NG tube
D. Prepare the patient for a laparoscopic surgery - ✔✔C. Insert an NG tube
✔✔The nurse is assessing the client diagnosed with long-term peripheral artery
disease. Which assessment data support the diagnosis?
A. Hairless skin on legs
B. Brittle flaky toenails
C. Petechiae on the soles of feet
D. Nonpitting ankle edema - ✔✔A. Hairless skin on legs
The lack of oxygen rich blood will cause the loss of hair on the tops of the feet and the
lower legs
✔✔The client is being admitted with Coumadin (Warfarin) toxicity. Which laboratory
data should the nurse monitor?
A. Blood urea nitrogen (BUN)