MED SURG HESI VERSION VERSION A+ GRAD
QUESTIONS AND ANSWERS VERIFIED AND E
GUARANTEED
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.
2. Increased blood flow.
3. Decreased pain.
4. Increased blood viscosity. - ANSWER 1. Decreased blood flow.
, A client with PVD and heart failure will experience decreased blood flow. In
this situation, low exercise tolerance (oxygen demand becomes greater than the
oxygen supply) may be related to less blood being ejected from the left ventricle into
the systemic circulation. Decreased blood supply to the tissues results in pain.
Increased blood viscosity may be a component, but it is of much less importance
than the disease processes.
When assessing the lower extremities of a client with peripheral vascular disease
(PVD), the nurse notes bilateral ankle edema. The edema is related to:
1. Competent venous valves.
2. Decreased blood volume.
3. Increase in muscular activity.
4. Increased venous pressure. - ANSWER 4. Increased venous pressure.
In PVD, decreased blood flow can result in increased venous pressure. The increase
in venous pressure results in an increase in capillary hydrostatic pressure, which
causes a net filtration of fluid out of the capillaries into the interstitial space, resulting
in edema. Valves often become incompetent with PVD. Blood volume is not
decreased in this condition. Decreased muscular action would contribute to the
formation of edema in the lower extremities.
CN: Reduction of risk potential; CL: Analyze
The nurse is teaching a client about risk factors associated with atherosclerosis and
how to reduce the risk. Which of the following is a risk factor that the client is not able
to modify?
1. Diabetes.
2. Age.
3. Exercise level.
4. Dietary preferences. - ANSWER 2. Age.
Age is a nonmodifiable risk factor for atherosclerosis. The nurse instructs the client
to manage modifiable risk factors such as comorbid diseases (eg, diabetes), activity
level, and diet. Controlling serum blood glucose levels, engaging in regular aerobic
activity, and choosing a diet low in saturated fats can reduce the risk of
developing atherosclerosis.
The nurse is assessing the lower extremities of the client with peripheral vascular
disease (PVD). During the assessment, the nurse should expect to find which of the
following clinical manifestations of PVD? Select all that apply.
1. Hairy legs.
2. Mottled skin.
3. Pink skin.
4. Coolness.
5. Moist skin. - ANSWER 2. Mottled skin
4. Coolness.
QUESTIONS AND ANSWERS VERIFIED AND E
GUARANTEED
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.
2. Increased blood flow.
3. Decreased pain.
4. Increased blood viscosity. - ANSWER 1. Decreased blood flow.
, A client with PVD and heart failure will experience decreased blood flow. In
this situation, low exercise tolerance (oxygen demand becomes greater than the
oxygen supply) may be related to less blood being ejected from the left ventricle into
the systemic circulation. Decreased blood supply to the tissues results in pain.
Increased blood viscosity may be a component, but it is of much less importance
than the disease processes.
When assessing the lower extremities of a client with peripheral vascular disease
(PVD), the nurse notes bilateral ankle edema. The edema is related to:
1. Competent venous valves.
2. Decreased blood volume.
3. Increase in muscular activity.
4. Increased venous pressure. - ANSWER 4. Increased venous pressure.
In PVD, decreased blood flow can result in increased venous pressure. The increase
in venous pressure results in an increase in capillary hydrostatic pressure, which
causes a net filtration of fluid out of the capillaries into the interstitial space, resulting
in edema. Valves often become incompetent with PVD. Blood volume is not
decreased in this condition. Decreased muscular action would contribute to the
formation of edema in the lower extremities.
CN: Reduction of risk potential; CL: Analyze
The nurse is teaching a client about risk factors associated with atherosclerosis and
how to reduce the risk. Which of the following is a risk factor that the client is not able
to modify?
1. Diabetes.
2. Age.
3. Exercise level.
4. Dietary preferences. - ANSWER 2. Age.
Age is a nonmodifiable risk factor for atherosclerosis. The nurse instructs the client
to manage modifiable risk factors such as comorbid diseases (eg, diabetes), activity
level, and diet. Controlling serum blood glucose levels, engaging in regular aerobic
activity, and choosing a diet low in saturated fats can reduce the risk of
developing atherosclerosis.
The nurse is assessing the lower extremities of the client with peripheral vascular
disease (PVD). During the assessment, the nurse should expect to find which of the
following clinical manifestations of PVD? Select all that apply.
1. Hairy legs.
2. Mottled skin.
3. Pink skin.
4. Coolness.
5. Moist skin. - ANSWER 2. Mottled skin
4. Coolness.
