Peripheral Vascular
NURS EXAM MED SURGE 1:
QUESTIONS WITH ANSWERS 2023 A+ SUCCESS
GURANTEED
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.
Correct answer: 2
1. Intermittent claudication is a symptom of arterial occlusive disease; therefore, this client
does not need to be assessed first.
2. The client with calf pain could be experiencing deep vein thrombosis (DVT), a complication
of immobility, which may be fatal if a pulmonary embolus occurs; therefore, this client should
be assessed first.
3. The client experiencing low back pain when sitting in a chair should be assessed but not prior
to the client with suspected DVT.
4. The nurse should address the client’s concern about the food, but it is not priority over
a physiological problem.
MAKING NURSING DECISIONS: When deciding which client to assess first, the test taker
should determine whether the signs/symptoms the client is exhibiting are normal or expected for
the client situation. After eliminating the expected options, the test taker should determine which
situation is more life threatening.
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).
Correct answer: 1
, Peripheral Vascular
NURS EXAM MED SURGE 1:
QUESTIONS WITH ANSWERS 2023 A+ SUCCESS
GURANTEED
1. Therapeutic levels for PTT should be 1.5 to 2 times the normal value, which is 39 seconds;
therefore, this client is at risk for bleeding. The prolonged PTT indicates the client is receiving
heparin (drug of choice to treat DVT). The nurse should stop the infusion and follow the
facility protocol.
{Normal aPTT is 28 - 35 seconds, depending on the type of activator used in testing.
• Therapeutic dose of heparin for Tx of DVT is to keep the aPTT between 1.5 (42
to 52.5) and 2.5 (70 to 87.5) times normal (control).
• This means that the pt’s value should not be < 42 seconds or >87.5 seconds.
• For PTT < 42 sec, the nurse needs to increase the rate of Heparin (based on
a sliding scale “Protocol”.
• For PTT > 87.5 sec, the nurse needs to decrease the rate of Heparin (and
if PTT is too high, stop heparin and prepare Protamine Sulfate (Antidote
of Heparin)}
2. The hemoglobin is within normal range and the client with Raynaud’s disease does not have
a problem with bleeding.
3. The WBC count is elevated (normal is 5,000 to 10,000), but it would be elevated in a
client who has an infection such as venous stasis ulcer.
4. The nurse should notify the HCP on rounds of any laboratory data that are abnormal but not
immediately life threatening. The triglyceride level is high, but it will take weeks to months of
a heart healthy diet, exercise, and possibly medications to lower this level.
MAKING NURSING DECISIONS: When a question asks for immediate intervention, the test
taker must decide whether there is an intervention the nurse can implement immediately or
whether the HCP must be notified. If the data are abnormal—but not life threatening—then the
option can be eliminated as a possible correct answer.
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.
Correct answer: 4
1. The nurse should first assess the client to determine the status prior to notifying the HCP.
2. The unlicensed assistive personnel (UAP) has notified the nurse of a potentially serious
situation. The nurse must first assess the client prior to taking any action.
3 The nurse might place the client in Trendelenburg position once cardiovascular shock is
determined.
4. The nurse should immediately go to the client’s room to assess the client.
MAKING NURSING DECISIONS: Any time the nurse receives information about a client
, Peripheral Vascular
NURS EXAM MED SURGE 1:
QUESTIONS WITH ANSWERS 2023 A+ SUCCESS
GURANTEED
(who may be experiencing a complication) from another staff member, the nurse must assess the
, Peripheral Vascular
NURS EXAM MED SURGE 1:
QUESTIONS WITH ANSWERS 2023 A+ SUCCESS
GURANTEED
client. The nurse should not make decisions about the client’s needs based on another staff
member’s information.
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.”
Correct answer: 1
1. Because laboratory values called into a unit usually include critical values, the charge nurse
should tell the unit secretary “to show me any lab information that is called in immediately.”
The charge nurse must evaluate this information immediately.
2. Posting laboratory results is the responsibility of the laboratory staff, not the nursing staff.
3. This is unrealistic because laboratory data are important information that must be called in to
a unit when there is a critical value so that immediate action can be taken for the client’s welfare.
The secretary must know how to process the information.
4. The unit secretary should verify the information by repeating back the information at the time
of the call, not by making a second telephone call to the lab.
MAKING NURSING DECISIONS: The test taker must be knowledgeable of the roles of all
members of the multidisciplinary healthcare team, as well as HIPAA rules and regulations. The
nurse must ensure the healthcare team member knows appropriate actions to take in specific
situations. These will be tested on the NCLEX-RN®.
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.
Correct answer: 1
1. Vitamin K is the antidote for warfarin (Coumadin) overdose and is administered to a
client when his or her INR level is above the therapeutic 2–3; therefore, the nurse should
question administering this medication.
2. Inderal is administered to clients diagnosed with hypertension; therefore, the nurse would not
question administering this medication.
3. Procardia reduces the number of vasospastic attacks in clients with Raynaud’s disease;
NURS EXAM MED SURGE 1:
QUESTIONS WITH ANSWERS 2023 A+ SUCCESS
GURANTEED
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.
Correct answer: 2
1. Intermittent claudication is a symptom of arterial occlusive disease; therefore, this client
does not need to be assessed first.
2. The client with calf pain could be experiencing deep vein thrombosis (DVT), a complication
of immobility, which may be fatal if a pulmonary embolus occurs; therefore, this client should
be assessed first.
3. The client experiencing low back pain when sitting in a chair should be assessed but not prior
to the client with suspected DVT.
4. The nurse should address the client’s concern about the food, but it is not priority over
a physiological problem.
MAKING NURSING DECISIONS: When deciding which client to assess first, the test taker
should determine whether the signs/symptoms the client is exhibiting are normal or expected for
the client situation. After eliminating the expected options, the test taker should determine which
situation is more life threatening.
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).
Correct answer: 1
, Peripheral Vascular
NURS EXAM MED SURGE 1:
QUESTIONS WITH ANSWERS 2023 A+ SUCCESS
GURANTEED
1. Therapeutic levels for PTT should be 1.5 to 2 times the normal value, which is 39 seconds;
therefore, this client is at risk for bleeding. The prolonged PTT indicates the client is receiving
heparin (drug of choice to treat DVT). The nurse should stop the infusion and follow the
facility protocol.
{Normal aPTT is 28 - 35 seconds, depending on the type of activator used in testing.
• Therapeutic dose of heparin for Tx of DVT is to keep the aPTT between 1.5 (42
to 52.5) and 2.5 (70 to 87.5) times normal (control).
• This means that the pt’s value should not be < 42 seconds or >87.5 seconds.
• For PTT < 42 sec, the nurse needs to increase the rate of Heparin (based on
a sliding scale “Protocol”.
• For PTT > 87.5 sec, the nurse needs to decrease the rate of Heparin (and
if PTT is too high, stop heparin and prepare Protamine Sulfate (Antidote
of Heparin)}
2. The hemoglobin is within normal range and the client with Raynaud’s disease does not have
a problem with bleeding.
3. The WBC count is elevated (normal is 5,000 to 10,000), but it would be elevated in a
client who has an infection such as venous stasis ulcer.
4. The nurse should notify the HCP on rounds of any laboratory data that are abnormal but not
immediately life threatening. The triglyceride level is high, but it will take weeks to months of
a heart healthy diet, exercise, and possibly medications to lower this level.
MAKING NURSING DECISIONS: When a question asks for immediate intervention, the test
taker must decide whether there is an intervention the nurse can implement immediately or
whether the HCP must be notified. If the data are abnormal—but not life threatening—then the
option can be eliminated as a possible correct answer.
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.
Correct answer: 4
1. The nurse should first assess the client to determine the status prior to notifying the HCP.
2. The unlicensed assistive personnel (UAP) has notified the nurse of a potentially serious
situation. The nurse must first assess the client prior to taking any action.
3 The nurse might place the client in Trendelenburg position once cardiovascular shock is
determined.
4. The nurse should immediately go to the client’s room to assess the client.
MAKING NURSING DECISIONS: Any time the nurse receives information about a client
, Peripheral Vascular
NURS EXAM MED SURGE 1:
QUESTIONS WITH ANSWERS 2023 A+ SUCCESS
GURANTEED
(who may be experiencing a complication) from another staff member, the nurse must assess the
, Peripheral Vascular
NURS EXAM MED SURGE 1:
QUESTIONS WITH ANSWERS 2023 A+ SUCCESS
GURANTEED
client. The nurse should not make decisions about the client’s needs based on another staff
member’s information.
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.”
Correct answer: 1
1. Because laboratory values called into a unit usually include critical values, the charge nurse
should tell the unit secretary “to show me any lab information that is called in immediately.”
The charge nurse must evaluate this information immediately.
2. Posting laboratory results is the responsibility of the laboratory staff, not the nursing staff.
3. This is unrealistic because laboratory data are important information that must be called in to
a unit when there is a critical value so that immediate action can be taken for the client’s welfare.
The secretary must know how to process the information.
4. The unit secretary should verify the information by repeating back the information at the time
of the call, not by making a second telephone call to the lab.
MAKING NURSING DECISIONS: The test taker must be knowledgeable of the roles of all
members of the multidisciplinary healthcare team, as well as HIPAA rules and regulations. The
nurse must ensure the healthcare team member knows appropriate actions to take in specific
situations. These will be tested on the NCLEX-RN®.
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.
Correct answer: 1
1. Vitamin K is the antidote for warfarin (Coumadin) overdose and is administered to a
client when his or her INR level is above the therapeutic 2–3; therefore, the nurse should
question administering this medication.
2. Inderal is administered to clients diagnosed with hypertension; therefore, the nurse would not
question administering this medication.
3. Procardia reduces the number of vasospastic attacks in clients with Raynaud’s disease;
