NURSING Peripheral Vascular Management with Answers Provided

NURSING Peripheral Vascular Management 1. The nurse has finished receiving the morning change-of-shift report. Which client should the nurse assess first? 1. The client diagnosed with arterial occlusive disease who has intermittent claudication. 2. The client on strict bed rest who is complaining of calf pain and has a reddened calf. 3. The client who complains of low back pain when lying supine in the bed. 4. The client who is upset because the food doesn’t taste good and is cold all the time. 2. The nurse is caring for clients on a vascular disorder unit. Which laboratory data warrant immediate intervention by the nurse? 1. The PTT of 98 seconds for a client diagnosed with deep vein thrombosis (DVT). 2. The hemoglobin 11.4 for a client diagnosed with Raynaud’s phenomenon. 3. The white blood cell (WBC) count of 11,000 for a client with a stasis venous ulcer. 4. The triglyceride level of 312 mmol/L in a client diagnosed with hypertension (HTN). 3. The unlicensed assistive personnel (UAP) tells the nurse the client has a blood pressure of 78/46 and a pulse of 116 using a vital signs machine. Which intervention should the nurse implement first? 1. Notify the healthcare provider immediately. 2. Have the UAP recheck the client’s vital signs manually. 3. Place the client in Trendelenburg position. 4. Assess the client’s cardiovascular status. 4. The charge nurse on a vascular unit is working with a new unit secretary. Which statement concerning laboratory data is most important for the charge nurse to tell the unit secretary? 1. “Be sure to show me any lab information that is called in to the unit.” 2. “Make sure to file the reports on the correct client’s chart.” 3. “Do not take any laboratory reports over the telephone.” 4. “Verify all telephone reports by calling back to the lab.” 5. The nurse on the vascular unit is preparing to administer medications to clients on a medical unit. Which medication should the nurse question administering? 1. Vitamin K (AquaMephyton), a vitamin, to a client with an International Normal Ratio (INR) of 2.8. 2. Propranolol (Inderal), a beta-adrenergic, to a client with arterial hypertension. 3. Nifedipine (Procardia), a calcium channel blocker, to a client with Raynaud’s disease. 4. Enalapril (Vasotec), an angiotensin-converting enzyme (ACE) inhibitor, to a client with a sodium level of 138 mEq/L. 6. The nurse has received the shift report. Which client should the nurse assess first? 1. The client with a deep vein thrombosis who is complaining of dyspnea and coughing. 2. The client diagnosed with Buerger’s disease who has intermittent claudication. 3. The client diagnosed with an aortic aneurysm who has an audible bruit. 4. The client with acute arterial ischemia who has bilateral palpable pedal pulses. 7. The female client diagnosed with atherosclerosis tells the clinic nurse her stomach hurts after she takes her morning medications. The client is taking a calcium channel blocker, a daily aspirin, and a statin. Which intervention should the nurse implement first? 1. Assess the client for abnormal bleeding. 2. Instruct the client to stop taking the aspirin. 3. Recommend the client take an enteric-coated aspirin. 4. Instruct the client to notify the HCP. 8. The nurse educator on a vascular unit is discussing delegation guidelines to a group of new graduates. Which statement from the group indicates the need for more teaching? 1. “The UAP will be practicing on my brand-new nursing license.” 2. “I will still retain accountability for what I delegate to the UAP.” 3. “I must make sure the UAP to whom I delegate is competent to perform the task.” 4. “When I delegate, I must follow up with the UAP and evaluate the task.” 9. The nurse is reviewing the literature to identify evidence-based practice research that supports a new procedure using a new product when changing the central line catheter dressing. Which research article would best support the nurse’s proposal for a change in the procedure? 1. The article in which the study was conducted by the manufacturer of the product used. 2. The research article that included 10 subjects participating in the study. 3. The review-of-literature article that cited ambiguous statistics about the product. 4. The review-of-literature article that cited numerous studies supporting the product. 10. The nurse and the unlicensed assistive personnel are caring for clients on a vascular unit. Which task is most appropriate for the nurse to delegate? 1. Provide indwelling catheter care to a client on bed rest. 2. Evaluate the client’s 8-hour intake and output. 3. Give a bath to the client who is third-spacing. 4. Administer a cation-exchange resin enema to a client. 11. The nurse asks the female UAP to apply the sequential compression devices (SCDs) to a client who is on strict bed rest. The UAP tells the nurse that she has never done this procedure. Which action would be priority for the nurse to take? 1. Tell another UAP to put the SCDs on the client. 2. Demonstrate the procedure for applying the SCDs. 3. Perform the task and apply the SCDs to the client. 4. Request the UAP watch the video demonstrating this task. 12. The nurse in the vascular critical care unit is working with an LPN who was pulled to the unit as a result of high census. Which task is most appropriate for the nurse to assign to the LPN? 1. Assess the client who will be transferred to the medical unit in the morning. 2. Administer a unit of blood to the client who is 1 day postoperative. 3. Hang the bag of heparin for a client diagnosed with a pulmonary embolus. 4. Assist the HCP with the insertion of a client’s Swan-Ganz line. 13. The nurse is administering one unit of packed red blood cells to a client. Fifteen minutes after initiation of the blood transfusion, the client becomes restless and complains of itching on the trunk and arms. Which intervention should the nurse implement first? 1. Assess the client’s vital signs. 2. Notify the HCP. 3. Maintain a patent IV line. 4. Stop the transfusion at the hub. 14. The staff nurse on a vascular disorder unit asks the charge nurse, “What should I be looking for when I read a research article?” Which response indicates the charge nurse does not understand how to read a nursing research article? 1. “You should be able to determine why the research was done.” 2. “You should look to find out how much money was used for the study.” 3. “You should evaluate which research method was used for the study.” 4. “You should read the method section to find out what setting was used.” 15. The nurse calls the HCP for an order for pain medication for a client who is 2 days postoperative aortic aneurysm repair. The HCP gives the nurse an order for “Demerol 50 mg IVP now and then every 4 hours as needed.” Which action should the nurse implement first?