HESI RN: Med-Surg - Version 2
The nurse is assessing a 48-year-old client with a history of smoking
during a routine clinic visit. The client, who exercises regularly, reports
having pain in the calf
during exercise that disappears at rest. Which of the following findings
requires further evaluation?
1. Heart rate 57 bpm.
2. SpO2 of 94% on room air.
3. Blood pressure 134/82.
4. Ankle-brachial index of 0.65. - ANSWER>>>4. Ankle-brachial index
of 0.65.
An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular
disease in a client who is experiencing intermittent claudication.
Normal ABI 1-1.4. A Doppler ultrasound is indicated for further
evaluation. The bradycardic heart rate is acceptable in an athletic
client with a normal blood pressure. The SpO2 is acceptable; the
client has a smoking history.
A client with peripheral vascular disease has undergone a right
femoral popliteal bypass graft. The blood pressure has decreased
from 124/80 to 94/62. What should the nurse assess first?
1. IV fluid solution.
2. Pedal pulses.
3. Nasal cannula flow rate.
4. Capillary refill. - ANSWER>>>2. Pedal pulses.
With each set of vital signs, the nurse should assess the dorsalis
pedis and posterior tibial pulses. The nurse needs to ensure adequate
perfusion to the lower
,extremity with the drop in blood pressure. IV fluids, nasal cannula
setting, and capillary refill are important to assess; however, priority is
to determine the cause of drop in blood pressure and that adequate
perfusion through the new graft is maintained.
CN: Reduction of risk potential; CL: Analyze
An overweight client taking warfarin (Coumadin) has dry skin due to
decreased arterial blood flow. What should the nurse instruct the client
to do? Select all that apply.
1. Apply lanolin or petroleum jelly to intact skin.
2. Follow a reduced-calorie, reduced-fat diet.- promote circulation by
reducing weight.
3. Inspect the involved areas daily for new ulcerations.
4. Instruct the client to limit activities of daily living (ADLs). 5. Use an
electric razor to shave. - ANSWER>>>1. Apply lanolin or petroleum
jelly to intact skin.
2. Follow a reduced-calorie, reduced-fat diet.- promote circulation by
reducing weight.
3. Inspect the involved areas daily for new ulcerations.
5. Use an electric razor to shave.
1, 2, 3, 5. Maintaining skin integrity is important in preventing chronic
ulcers and infections. The client should be taught to inspect the skin
on a daily basis. The client should reduce weight to promote
circulation; a diet lower in calories and fat is appropriate. Because the
client is receiving Coumadin, the client is at risk for bleeding from cuts.
To decrease the risk of cuts, the nurse should suggest that the client
use an electric razor. The client with decreased arterial blood flow
should be encouraged to participate in ADLs. In fact, the client should
be encouraged to consult an exercise physiologist for an exercise
program that enhances the aerobic capacity of the body. CN: Health
promotion and maintenance; CL: Synthesize
The nurse is caring for a client with peripheral artery disease who has
recently been prescribed clopidogrel (Plavix). The nurse understands
,that more teaching is necessary when the client states which of the
following:
1. "I should not be surprised if I bruise easier or if my gums bleed a
little when brushing my teeth."
2. "It doesn't really matter if I take this medicine with or without food,
whatever works best for my stomach."
3. "I should stop taking Plavix if it makes me feel weak and dizzy."
4. "The doctor prescribed this medicine to make my platelets less
likely to stick together and help prevent clots from forming." -
ANSWER>>>3. "I should stop taking Plavix if it makes me feel weak
and dizzy."
Weakness, dizziness, and headache are common adverse effects of
Plavix and the client should report these to the physician if they are
problematic; in order to decrease risk of clot formation, Plavix must be
taken regularly and should not be
stopped or taken intermittently. The main adverse effect of Plavix is
bleeding, which often occurs as increased bruising or bleeding when
brushing teeth. Plavix is well absorbed, and while food may help
decrease potential gastrointestinal upset, Plavix may be taken with or
without food. Plavix is an antiplatelet agent used to prevent clot
formation in clients who have experienced or are at risk for myocardial
infarction, ischemic stroke, peripheral artery disease, or acute
coronary syndrome.
CN: Pharmacological and parenteral therapies; CL: Evaluate
A client is receiving Cilostazol (Pletal) for peripheral arterial disease
causing intermittent claudication. The nurse determines this
medication is effective when the client reports which of the following?
1. "I am having fewer aches and pains."
2. "I do not have headaches anymore."
3. "I am able to walk further without leg pain."
4. "My toes are turning grayish black in color." - ANSWER>>>3. "I am
able to walk further without leg pain."
Cilostazol is indicated for management of intermittent claudication.
Symptoms usually improve within 2 to 4 weeks of therapy. Intermittent
, claudication prevents clients from walking for long periods of time.
Cilostazol inhibits platelet aggregation induced by various stimuli and
improving blood flow to the muscles and allowing the client to walk
long distances without pain. Peripheral arterial disease causes pain
mainly of the leg muscles. "Aches and pains" does not specify exactly
where the pain is occurring. Headaches may occur as a side effect of
this drug, and the client should report this information to the health
care provider. Peripheral arterial disease causes
decreased blood supply to the peripheral tissues and may cause
gangrene of the toes; the drug is effective when the toes are warm to
the touch and the color of the toes is similar
to the color of the body.
CN: Pharmacological and parenteral therapies; CL: Evaluate
The client admitted with peripheral vascular disease (PVD) asks the
nurse why
her legs hurt when she walks. The nurse bases a response on the
knowledge that the main characteristic of PVD is:
1. Decreased blood flow.
2. Increased blood flow.
3. Slow blood flow.
4. Thrombus formation. - ANSWER>>>1. Decreased blood flow.
Decreased blood flow is a common characteristic of all PVD. When
the demand for oxygen to the working muscles becomes greater than
the supply, pain is the outcome. Slow blood flow throughout the
circulatory system may suggest pump failure. Thrombus formation can
result from stasis or damage to the intima of the vessels.
The nurse is planning care for a client who is diagnosed with
peripheral vascular disease (PVD) and has a history of heart failure.
The nurse should develop a plan of care that is based on the fact that
the client may have a low tolerance for exercise related to:
1. Decreased blood flow.
The nurse is assessing a 48-year-old client with a history of smoking
during a routine clinic visit. The client, who exercises regularly, reports
having pain in the calf
during exercise that disappears at rest. Which of the following findings
requires further evaluation?
1. Heart rate 57 bpm.
2. SpO2 of 94% on room air.
3. Blood pressure 134/82.
4. Ankle-brachial index of 0.65. - ANSWER>>>4. Ankle-brachial index
of 0.65.
An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular
disease in a client who is experiencing intermittent claudication.
Normal ABI 1-1.4. A Doppler ultrasound is indicated for further
evaluation. The bradycardic heart rate is acceptable in an athletic
client with a normal blood pressure. The SpO2 is acceptable; the
client has a smoking history.
A client with peripheral vascular disease has undergone a right
femoral popliteal bypass graft. The blood pressure has decreased
from 124/80 to 94/62. What should the nurse assess first?
1. IV fluid solution.
2. Pedal pulses.
3. Nasal cannula flow rate.
4. Capillary refill. - ANSWER>>>2. Pedal pulses.
With each set of vital signs, the nurse should assess the dorsalis
pedis and posterior tibial pulses. The nurse needs to ensure adequate
perfusion to the lower
,extremity with the drop in blood pressure. IV fluids, nasal cannula
setting, and capillary refill are important to assess; however, priority is
to determine the cause of drop in blood pressure and that adequate
perfusion through the new graft is maintained.
CN: Reduction of risk potential; CL: Analyze
An overweight client taking warfarin (Coumadin) has dry skin due to
decreased arterial blood flow. What should the nurse instruct the client
to do? Select all that apply.
1. Apply lanolin or petroleum jelly to intact skin.
2. Follow a reduced-calorie, reduced-fat diet.- promote circulation by
reducing weight.
3. Inspect the involved areas daily for new ulcerations.
4. Instruct the client to limit activities of daily living (ADLs). 5. Use an
electric razor to shave. - ANSWER>>>1. Apply lanolin or petroleum
jelly to intact skin.
2. Follow a reduced-calorie, reduced-fat diet.- promote circulation by
reducing weight.
3. Inspect the involved areas daily for new ulcerations.
5. Use an electric razor to shave.
1, 2, 3, 5. Maintaining skin integrity is important in preventing chronic
ulcers and infections. The client should be taught to inspect the skin
on a daily basis. The client should reduce weight to promote
circulation; a diet lower in calories and fat is appropriate. Because the
client is receiving Coumadin, the client is at risk for bleeding from cuts.
To decrease the risk of cuts, the nurse should suggest that the client
use an electric razor. The client with decreased arterial blood flow
should be encouraged to participate in ADLs. In fact, the client should
be encouraged to consult an exercise physiologist for an exercise
program that enhances the aerobic capacity of the body. CN: Health
promotion and maintenance; CL: Synthesize
The nurse is caring for a client with peripheral artery disease who has
recently been prescribed clopidogrel (Plavix). The nurse understands
,that more teaching is necessary when the client states which of the
following:
1. "I should not be surprised if I bruise easier or if my gums bleed a
little when brushing my teeth."
2. "It doesn't really matter if I take this medicine with or without food,
whatever works best for my stomach."
3. "I should stop taking Plavix if it makes me feel weak and dizzy."
4. "The doctor prescribed this medicine to make my platelets less
likely to stick together and help prevent clots from forming." -
ANSWER>>>3. "I should stop taking Plavix if it makes me feel weak
and dizzy."
Weakness, dizziness, and headache are common adverse effects of
Plavix and the client should report these to the physician if they are
problematic; in order to decrease risk of clot formation, Plavix must be
taken regularly and should not be
stopped or taken intermittently. The main adverse effect of Plavix is
bleeding, which often occurs as increased bruising or bleeding when
brushing teeth. Plavix is well absorbed, and while food may help
decrease potential gastrointestinal upset, Plavix may be taken with or
without food. Plavix is an antiplatelet agent used to prevent clot
formation in clients who have experienced or are at risk for myocardial
infarction, ischemic stroke, peripheral artery disease, or acute
coronary syndrome.
CN: Pharmacological and parenteral therapies; CL: Evaluate
A client is receiving Cilostazol (Pletal) for peripheral arterial disease
causing intermittent claudication. The nurse determines this
medication is effective when the client reports which of the following?
1. "I am having fewer aches and pains."
2. "I do not have headaches anymore."
3. "I am able to walk further without leg pain."
4. "My toes are turning grayish black in color." - ANSWER>>>3. "I am
able to walk further without leg pain."
Cilostazol is indicated for management of intermittent claudication.
Symptoms usually improve within 2 to 4 weeks of therapy. Intermittent
, claudication prevents clients from walking for long periods of time.
Cilostazol inhibits platelet aggregation induced by various stimuli and
improving blood flow to the muscles and allowing the client to walk
long distances without pain. Peripheral arterial disease causes pain
mainly of the leg muscles. "Aches and pains" does not specify exactly
where the pain is occurring. Headaches may occur as a side effect of
this drug, and the client should report this information to the health
care provider. Peripheral arterial disease causes
decreased blood supply to the peripheral tissues and may cause
gangrene of the toes; the drug is effective when the toes are warm to
the touch and the color of the toes is similar
to the color of the body.
CN: Pharmacological and parenteral therapies; CL: Evaluate
The client admitted with peripheral vascular disease (PVD) asks the
nurse why
her legs hurt when she walks. The nurse bases a response on the
knowledge that the main characteristic of PVD is:
1. Decreased blood flow.
2. Increased blood flow.
3. Slow blood flow.
4. Thrombus formation. - ANSWER>>>1. Decreased blood flow.
Decreased blood flow is a common characteristic of all PVD. When
the demand for oxygen to the working muscles becomes greater than
the supply, pain is the outcome. Slow blood flow throughout the
circulatory system may suggest pump failure. Thrombus formation can
result from stasis or damage to the intima of the vessels.
The nurse is planning care for a client who is diagnosed with
peripheral vascular disease (PVD) and has a history of heart failure.
The nurse should develop a plan of care that is based on the fact that
the client may have a low tolerance for exercise related to:
1. Decreased blood flow.
