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.
4
An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular disease in a
client who is experiencing intermittent claudication. 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.
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.
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
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.
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
,2
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.
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."
3
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.
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."
3
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.
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.
1
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.
1
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.
4
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.
The nurse is obtaining the pulse of a client who has had a femoral-
popliteal bypass surgery 6 hours ago. (See below) Which assessment
provides the most accurate information about the client's postoperative
status?
1. radial pulse
2. femoral pulse
3. apical pulse
4. dorsalis pedis pulse
4
The presence of a strong dorsalis pedis pulse indicates that there is circulation to
the extremity distal to the surgery indicating that the graft between the femoral and
popliteal artery is allowing blood to circulate effectively. Answer 1 shows the nurse
obtaining the radial pulse; answer 2 shows the femoral pulse, which is proximal to
the surgery site and will not indicate circulation distal to the surgery site. Answer 3
shows
the nurse obtaining an apical pulse.
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
2
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.
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.
4
An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular disease in a
client who is experiencing intermittent claudication. 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.
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.
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
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.
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
,2
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.
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."
3
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.
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."
3
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.
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.
1
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.
1
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.
4
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.
The nurse is obtaining the pulse of a client who has had a femoral-
popliteal bypass surgery 6 hours ago. (See below) Which assessment
provides the most accurate information about the client's postoperative
status?
1. radial pulse
2. femoral pulse
3. apical pulse
4. dorsalis pedis pulse
4
The presence of a strong dorsalis pedis pulse indicates that there is circulation to
the extremity distal to the surgery indicating that the graft between the femoral and
popliteal artery is allowing blood to circulate effectively. Answer 1 shows the nurse
obtaining the radial pulse; answer 2 shows the femoral pulse, which is proximal to
the surgery site and will not indicate circulation distal to the surgery site. Answer 3
shows
the nurse obtaining an apical pulse.
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
2
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.
