Nokea
The client states to the clinic nurse, “I had pain in the left calf for a few days earlier in the week, but I am pain free now.” The nurse’s assessment findings include: dorsalis pedis pulses palpable, no pain upon dorsiflexion bilaterally, a few visible varicose veins in each leg, and slight swelling in only the left leg. Which is the nurse’s best action?
- A. Ask if the client has been walking more lately.
- B. Inform the HCP of the assessment findings.
- C. Ask if the client has considered taking a baby aspirin daily.
- D. Explain to the client that there are no significant findings.
Correct Answer: B
Rationale: The nurse should inform the HCP about the assessment findings. A possible DVT is taken seriously because it can lead to PE. Unilateral swelling of one leg is a classic symptom of DVT. Additional questions, aspirin advice, or dismissing findings are inappropriate without further evaluation.
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While the nurse is assessing the client, the client says, “I had an endovascular repair of an AAA that was found 1 month ago during a routine physical.” The nurse’s assessment of the client should be based on understanding that this procedure involves which action?
- A. Excision to remove the aneurysm and place a graft percutaneously
- B. An angioplasty with placement of a stent around the outside of the aorta
- C. Placement of a filter within the aneurysm to block clots from becoming emboli
- D. Placement of a stent graft inside the aorta that excludes the aneurysm from circulation
Correct Answer: D
Rationale: The endovascular repair consists of placement of the endovascular stent graft inside the aorta, extending above and below the aneurysmal area to seal it off from the circulation. Excision, external stents, and filters are not involved.
Two days ago the client underwent femoral popliteal artery bypass graft surgery. What should be the nurse’s priority at this time?
- A. Monitor intake and output every four hours.
- B. Report any edema that develops in the operative leg.
- C. Place the client in a 60-degree sitting position when in bed.
- D. Check pedal and post tibial pulses bilaterally every 4 hours.
Correct Answer: D
Rationale: The priority nursing action should be to monitor the pulses in the feet to detect graft occlusion. Checking both sides allows for comparison. I&O, edema, and positioning are secondary.
The nurse completes teaching the client about CAD and self-care at home. The nurse determines that teaching is effective when the client makes which statements? Select all that apply.
- A. “If I have chest pain, I should contact my physician immediately.”
- B. “I should carry my nitroglycerin in my front pants pocket so it is handy.”
- C. “If I have chest pain, I stop activity and chew a nitroglycerin tablet.”
- D. “I should always take three nitroglycerin tablets, 5 minutes apart.”
- E. “I plan to avoid being around people when they are smoking.”
- F. “I plan on walking on most days of the week for at least 30 minutes.”
Correct Answer: E;F
Rationale: Teaching is effective when the client states: E) Avoiding passive smoke to prevent vasoconstriction; F) Walking 30 minutes most days as recommended by the American Heart Association. Contacting the physician immediately is incorrect (call 911), pants pockets are not ideal for nitroglycerin storage, nitroglycerin is taken sublingually not chewed, and three tablets are not always needed.
The client is admitted with acute infective endocarditis (IE). Which assessment findings should the nurse associate with IE? Select all that apply.
- A. Skin petechiae
- B. Crackles in lung bases
- C. Peripheral edema
- D. Murmur
- E. Arthralgia
- F. Hemangioma
Correct Answer: A;B;C;D;E
Rationale: The nurse should associate: A) Skin petechiae from microembolism; B) Crackles from HF secondary to IE; C) Peripheral edema from HF; D) Murmur from valve incompetence; E) Arthralgia from microembolism. Hemangioma is not associated with IE.
The nurse is caring for the client with a suspected DVT. For which diagnostic test should the nurse anticipate the client will need to be prepared?
- A. V/Q Scan
- B. Arteriogram
- C. Venogram
- D. Embolectomy
Correct Answer: C
Rationale: The nurse should anticipate preparing the client for a venogram, which allows visualization of veins and is used to diagnose a DVT. V/Q scans diagnose PE, arteriograms visualize arteries, and embolectomy is a treatment, not a diagnostic test.