NURS347 - Final Exam UPDATED Exam
Questions and CORRECT Answers
While performing an admission assessment for a client, the nurse notes that the client has
varicose veins with ulcerations and lower extremity edema with a report of a feeling of
heaviness. Which of the following nursing diagnoses should the nurse identify as being the
priority in the client's care?
a. Impaired skin integrity
b. Alteration in body image
c. Alteration in activity tolerance
d. Impaired tissue perfusion - CORRECT ANSWER - d. Impaired tissue perfusion
S.E. is a 30 year old Caucasian male with no significant past medical history and family history
is unremarkable. He had a recent basketball injury resulting in a torn Achilles tendon 3 weeks
ago and a non-weight bearing cast was placed. He is complaining of right calf pain. Which of the
following is indicative of deep vein thrombosis?
a. Left leg tan with pale cool toes
b. Dull throbbing right leg pain with cold pale toes
c. Intermittent sharp stabbing right ankle pain without edema
d. Right calf slightly red and swollen a few cm larger than the left calf with all pulses equal
bilaterally. - CORRECT ANSWER - d. Right calf slightly red and swollen a few cm
larger than the left calf with all pulses equal bilaterally.
A patient has been diagnosed with venous stasis. Which of these findings would the nurse most
likely observe?
a. Brownish discoloration to the skin of the lower leg
b. Pallor of the toes and cyanosis of the nail beds
c. Thin, shiny, atrophic skin
d. Unilateral cool foot - CORRECT ANSWER - a. Brownish discoloration to the skin of
the lower leg
,When performing an assessment of a patient, the nurse notices the presence of an enlarged right
epitrochlear lymph node. What should the nurse do next?
a. Ask additional health history questions regarding any recent ear infections or sore throats
b. Assess the patient's abdomen, and notice any tenderness
c. Carefully assess the cervical lymph nodes, and check for any enlargement
d. Examine the patient's lower arm and hand, and check for the presence of infection or lesions -
CORRECT ANSWER - d. Examine the patient's lower arm and hand, and check for the
presence of infection or lesions
A patient complains of leg pain that wakes him at night. He states that he "has been having
problems" with his legs. He has pain in his legs when they are elevated that disappears when he
dangles them. He recently noticed "a sore" on the inner aspect of the right ankle. On the basis of
this health history information, the nurse interprets that the patient is most likely experiencing:
a. Problems related to venous insufficiency
b. Pain related to lymphatic abnormalities
c. Pain related to musculoskeletal abnormalities
d. Problems related to arterial insufficiency - CORRECT ANSWER - d. Problems related
to arterial insufficiency
During an assessment, a patient tells the nurse that her fingers often change color when she goes
out in cold weather. She describes these episodes as her fingers first turning white, then blue,
then red with a burning, throbbing pain. The nurse suspects that she is experiencing:
a. Chronic arterial insufficiency
b. Raynaud's phenomenon
c. Lymphedema
d. Deep-vein thrombosis - CORRECT ANSWER - b. Raynaud's phenomenon
A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both
hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the
following locations?
a. Toe
b. Skin fold
,c. Earlobe
d. Finger - CORRECT ANSWER - c. Earlobe
When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the
ulnar pulses. The patient's skin is warm and capillary refill time is normal. Next, the nurse
should:
a. Ask the patient if he or she has experienced any unusual cramping or tingling in the arm
b. Consider this finding as normal, and proceed with the peripheral vascular evaluation
c. Check for the presence of claudication
d. Refer the individual for further evaluation - CORRECT ANSWER - b. Consider this
finding as normal, and proceed with the peripheral vascular evaluation
The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for
palpation?
a. Over the lateral malleolus
b. In the groove behind the medial malleolus
c. Behind the knee
d. Lateral to the extensor tendon of the great toe - CORRECT ANSWER - d. Lateral to
the extensor tendon of the great toe
A nurse is assessing a client for pitting edema and notes an indentation of 6 mm (0.25 in) at the
point of pressure. Which of the following notations should the nurse use to document the severity
of the client's edema?
a. 1+
b. 2+
c. 3+
d. 4+ - CORRECT ANSWER - c. 3+
How should the nurse document mild, slight pitting edema the ankles of a pregnant patient?
a. 2+
, b. 4+
c. 1+
d. 3+ - CORRECT ANSWER - c. 1+
Claudication is caused by:
a. Venous insufficiency
b. arterial insufficiency
c. stasis ulcerations
d. Varicose veins - CORRECT ANSWER - b. arterial insufficiency
The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the
documentation states that the radial pulses are "1+." The nurse recognizes that this reading
indicates what type of pulse?
a. Normal
b. Absent
c. Weak
d. Bounding - CORRECT ANSWER - c. weak
The nurse is reviewing the risk factors for venous disease. Which of these situations best
describes a person at highest risk for the development of venous disease?
a. Women in her second month of pregnancy
b. Person with a 30-year, 1 pack a day smoking habit
c. Older adult taking anticoagulant medication
d. Person who has been on bed rest for 4 days - CORRECT ANSWER - d. Person who
has been on bed rest for 4 days
A patient's abdomen is bulging and stretched in appearance. The nurse should describe this
finding as:
a. Obese.
b. Herniated.
Questions and CORRECT Answers
While performing an admission assessment for a client, the nurse notes that the client has
varicose veins with ulcerations and lower extremity edema with a report of a feeling of
heaviness. Which of the following nursing diagnoses should the nurse identify as being the
priority in the client's care?
a. Impaired skin integrity
b. Alteration in body image
c. Alteration in activity tolerance
d. Impaired tissue perfusion - CORRECT ANSWER - d. Impaired tissue perfusion
S.E. is a 30 year old Caucasian male with no significant past medical history and family history
is unremarkable. He had a recent basketball injury resulting in a torn Achilles tendon 3 weeks
ago and a non-weight bearing cast was placed. He is complaining of right calf pain. Which of the
following is indicative of deep vein thrombosis?
a. Left leg tan with pale cool toes
b. Dull throbbing right leg pain with cold pale toes
c. Intermittent sharp stabbing right ankle pain without edema
d. Right calf slightly red and swollen a few cm larger than the left calf with all pulses equal
bilaterally. - CORRECT ANSWER - d. Right calf slightly red and swollen a few cm
larger than the left calf with all pulses equal bilaterally.
A patient has been diagnosed with venous stasis. Which of these findings would the nurse most
likely observe?
a. Brownish discoloration to the skin of the lower leg
b. Pallor of the toes and cyanosis of the nail beds
c. Thin, shiny, atrophic skin
d. Unilateral cool foot - CORRECT ANSWER - a. Brownish discoloration to the skin of
the lower leg
,When performing an assessment of a patient, the nurse notices the presence of an enlarged right
epitrochlear lymph node. What should the nurse do next?
a. Ask additional health history questions regarding any recent ear infections or sore throats
b. Assess the patient's abdomen, and notice any tenderness
c. Carefully assess the cervical lymph nodes, and check for any enlargement
d. Examine the patient's lower arm and hand, and check for the presence of infection or lesions -
CORRECT ANSWER - d. Examine the patient's lower arm and hand, and check for the
presence of infection or lesions
A patient complains of leg pain that wakes him at night. He states that he "has been having
problems" with his legs. He has pain in his legs when they are elevated that disappears when he
dangles them. He recently noticed "a sore" on the inner aspect of the right ankle. On the basis of
this health history information, the nurse interprets that the patient is most likely experiencing:
a. Problems related to venous insufficiency
b. Pain related to lymphatic abnormalities
c. Pain related to musculoskeletal abnormalities
d. Problems related to arterial insufficiency - CORRECT ANSWER - d. Problems related
to arterial insufficiency
During an assessment, a patient tells the nurse that her fingers often change color when she goes
out in cold weather. She describes these episodes as her fingers first turning white, then blue,
then red with a burning, throbbing pain. The nurse suspects that she is experiencing:
a. Chronic arterial insufficiency
b. Raynaud's phenomenon
c. Lymphedema
d. Deep-vein thrombosis - CORRECT ANSWER - b. Raynaud's phenomenon
A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both
hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the
following locations?
a. Toe
b. Skin fold
,c. Earlobe
d. Finger - CORRECT ANSWER - c. Earlobe
When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the
ulnar pulses. The patient's skin is warm and capillary refill time is normal. Next, the nurse
should:
a. Ask the patient if he or she has experienced any unusual cramping or tingling in the arm
b. Consider this finding as normal, and proceed with the peripheral vascular evaluation
c. Check for the presence of claudication
d. Refer the individual for further evaluation - CORRECT ANSWER - b. Consider this
finding as normal, and proceed with the peripheral vascular evaluation
The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for
palpation?
a. Over the lateral malleolus
b. In the groove behind the medial malleolus
c. Behind the knee
d. Lateral to the extensor tendon of the great toe - CORRECT ANSWER - d. Lateral to
the extensor tendon of the great toe
A nurse is assessing a client for pitting edema and notes an indentation of 6 mm (0.25 in) at the
point of pressure. Which of the following notations should the nurse use to document the severity
of the client's edema?
a. 1+
b. 2+
c. 3+
d. 4+ - CORRECT ANSWER - c. 3+
How should the nurse document mild, slight pitting edema the ankles of a pregnant patient?
a. 2+
, b. 4+
c. 1+
d. 3+ - CORRECT ANSWER - c. 1+
Claudication is caused by:
a. Venous insufficiency
b. arterial insufficiency
c. stasis ulcerations
d. Varicose veins - CORRECT ANSWER - b. arterial insufficiency
The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the
documentation states that the radial pulses are "1+." The nurse recognizes that this reading
indicates what type of pulse?
a. Normal
b. Absent
c. Weak
d. Bounding - CORRECT ANSWER - c. weak
The nurse is reviewing the risk factors for venous disease. Which of these situations best
describes a person at highest risk for the development of venous disease?
a. Women in her second month of pregnancy
b. Person with a 30-year, 1 pack a day smoking habit
c. Older adult taking anticoagulant medication
d. Person who has been on bed rest for 4 days - CORRECT ANSWER - d. Person who
has been on bed rest for 4 days
A patient's abdomen is bulging and stretched in appearance. The nurse should describe this
finding as:
a. Obese.
b. Herniated.
