BSN 266 SHERPATHS EXAMINATION
QUESTIONS WITH CORRECT
ANSWERS
Question 2 of 9
Which statement from a patient with a history of chronic venous insufficiency (CVI)
would lead the nurse to suspect a venous ulcer?
"I have several spots on my toes that are dark in color. I only just noticed them because
they don't hurt."
"I have a sore on the outside of my lower leg that is pink in color. It only hurts a little bit,
mostly when I put my legs up."
"I have a painful sore on the inside of my ankle that is yellow. I have to change the
dressing on it a lot because of all the drainage."
"I have a sore on the bottom of my foot that is circular in shape and smooth. When I
stand up, my foot gets really red." - Answer-"I have a painful sore on the inside of my
ankle that is yellow. I have to change the dressing on it a lot because of all the
drainage."
CVI ulcers are often near the medial malleolus and irregularly shaped with moderate
amounts of drainage. The tissue will be yellow or dark red, with "ruddy" granulation.
Question 3 of 9
Which patient is at highest risk for developing a venous ulcer?
A patient with elevated lipid levels
A patient with intermittent claudication
A patient with uncontrolled hypertension
A patient with uncontrolled varicose veins - Answer-A patient with uncontrolled varicose
veins
Both long-standing primary varicose veins and postthrombotic syndrome (PTS) can
progress to CVI and venous ulcers.
Question 4 of 9
A patient with varicose veins has just received sclerotherapy. What statement made by
the patient would cause the nurse to further assess the patient's understanding of post-
sclerotherapy care?
"I should elevate my legs to decrease swelling and the risk of clots."
"I will monitor my leg for signs of infection, such as redness, tenderness, or drainage."
"I am excited to leave for my trip tomorrow because I can finally relax without leg pain."
"I will be sure to always wear my graduated compression stockings to prevent clots from
developing." - Answer-"I am excited to leave for my trip tomorrow because I can finally
relax without leg pain."
, This patient response should prompt the nurse to further assess the patient's
understanding of sclerotherapy. Patients should not travel long distances during the first
week after sclerotherapy to minimize the risk of a venous thromboembolism (VTE).
Question 5 of 9
The patient with chronic venous insufficiency (CVI) and a lower extremity venous ulcer
presents to the clinic for a dressing change. Which assessment finding would cause the
nurse to consider other compression options?
Increased edema
Leg pain when sitting
Brownish skin discoloration
Itching surrounding the ulcer - Answer-Increased edema
Increased edema would indicate the need for alternative compression therapy options
as the current therapy is not adequately controlling edema.
Question 6 of 9
The nurse is changing the dressing of a venous ulcer that has foul smelling drainage,
redness, warmth, and increased edema of the surrounding skin. Which is the
appropriate collaborative care action?
Contact the health care provider about obtaining a wound culture.
Discuss the appropriate intravenous (IV) antibiotic with the pharmacist.
Refer to the home health nurse to order daily dressing changes at home.
Consult with the physical therapist to increase activity to help decrease edema. -
Answer-Contact the health care provider about obtaining a wound culture.
These assessment findings may indicate acute infection. The health care provider
should be notified to obtain an order for a wound culture.
Question 7 of 9
The nurse should provide education to which patient with a history of varicose veins
about prevention of recurrence?
A patient who is a server in a restaurant
A patient who continues to wear compression stockings
A patient who uses pillows under the legs while sleeping
A patient who is an editor and sits at a desk 8 hours a day - Answer-A patient who is an
editor and sits at a desk 8 hours a day
This patient is at higher risk for recurrence of varicose veins. The nurse should stress
the importance of periodically positioning the legs above heart level, which will help
decrease edema and the reoccurrence of varicose veins. Patients with a job that
requires long periods of sitting need to frequently flex and extend their hips, legs, and
ankles and change positions.
Question 8 of 9
The nurse is caring for a patient with chronic venous insufficiency (CVI) and a venous
ulcer. Which patient statement would cause the nurse to contact the ordering provider?
"My legs hurt when I sit down."
"My skin is so dry it is peeling."
QUESTIONS WITH CORRECT
ANSWERS
Question 2 of 9
Which statement from a patient with a history of chronic venous insufficiency (CVI)
would lead the nurse to suspect a venous ulcer?
"I have several spots on my toes that are dark in color. I only just noticed them because
they don't hurt."
"I have a sore on the outside of my lower leg that is pink in color. It only hurts a little bit,
mostly when I put my legs up."
"I have a painful sore on the inside of my ankle that is yellow. I have to change the
dressing on it a lot because of all the drainage."
"I have a sore on the bottom of my foot that is circular in shape and smooth. When I
stand up, my foot gets really red." - Answer-"I have a painful sore on the inside of my
ankle that is yellow. I have to change the dressing on it a lot because of all the
drainage."
CVI ulcers are often near the medial malleolus and irregularly shaped with moderate
amounts of drainage. The tissue will be yellow or dark red, with "ruddy" granulation.
Question 3 of 9
Which patient is at highest risk for developing a venous ulcer?
A patient with elevated lipid levels
A patient with intermittent claudication
A patient with uncontrolled hypertension
A patient with uncontrolled varicose veins - Answer-A patient with uncontrolled varicose
veins
Both long-standing primary varicose veins and postthrombotic syndrome (PTS) can
progress to CVI and venous ulcers.
Question 4 of 9
A patient with varicose veins has just received sclerotherapy. What statement made by
the patient would cause the nurse to further assess the patient's understanding of post-
sclerotherapy care?
"I should elevate my legs to decrease swelling and the risk of clots."
"I will monitor my leg for signs of infection, such as redness, tenderness, or drainage."
"I am excited to leave for my trip tomorrow because I can finally relax without leg pain."
"I will be sure to always wear my graduated compression stockings to prevent clots from
developing." - Answer-"I am excited to leave for my trip tomorrow because I can finally
relax without leg pain."
, This patient response should prompt the nurse to further assess the patient's
understanding of sclerotherapy. Patients should not travel long distances during the first
week after sclerotherapy to minimize the risk of a venous thromboembolism (VTE).
Question 5 of 9
The patient with chronic venous insufficiency (CVI) and a lower extremity venous ulcer
presents to the clinic for a dressing change. Which assessment finding would cause the
nurse to consider other compression options?
Increased edema
Leg pain when sitting
Brownish skin discoloration
Itching surrounding the ulcer - Answer-Increased edema
Increased edema would indicate the need for alternative compression therapy options
as the current therapy is not adequately controlling edema.
Question 6 of 9
The nurse is changing the dressing of a venous ulcer that has foul smelling drainage,
redness, warmth, and increased edema of the surrounding skin. Which is the
appropriate collaborative care action?
Contact the health care provider about obtaining a wound culture.
Discuss the appropriate intravenous (IV) antibiotic with the pharmacist.
Refer to the home health nurse to order daily dressing changes at home.
Consult with the physical therapist to increase activity to help decrease edema. -
Answer-Contact the health care provider about obtaining a wound culture.
These assessment findings may indicate acute infection. The health care provider
should be notified to obtain an order for a wound culture.
Question 7 of 9
The nurse should provide education to which patient with a history of varicose veins
about prevention of recurrence?
A patient who is a server in a restaurant
A patient who continues to wear compression stockings
A patient who uses pillows under the legs while sleeping
A patient who is an editor and sits at a desk 8 hours a day - Answer-A patient who is an
editor and sits at a desk 8 hours a day
This patient is at higher risk for recurrence of varicose veins. The nurse should stress
the importance of periodically positioning the legs above heart level, which will help
decrease edema and the reoccurrence of varicose veins. Patients with a job that
requires long periods of sitting need to frequently flex and extend their hips, legs, and
ankles and change positions.
Question 8 of 9
The nurse is caring for a patient with chronic venous insufficiency (CVI) and a venous
ulcer. Which patient statement would cause the nurse to contact the ordering provider?
"My legs hurt when I sit down."
"My skin is so dry it is peeling."
