DVT/PVD/PE/HTN/ED-TESTBANK
1) What will the nurse most likely assess in a client with right heart failure?
A) Leg cramps
B) Indigestion
C) Reduced circulation to the pulmonary structures
D) Reduced urine output - Correct Answers -C) Reduced circulation to the pulmonary
structures
Circulation to the pulmonary structures begins with the right side of the heart. The client
with right heart failure will have reduced circulation to these structures. There is no
evidence to suggest that right heart failure will cause indigestion or reduced urine
output. Not all clients with right heart failure experience leg cramps.
The nurse is concerned that a client with an alteration in perfusion is at risk for
inadequate oxygenation. What should the nurse consider when planning for this client's
potential health problem?
A) Cluster activities.
B) Instruct on deep breathing.
C) Medications appropriate to increase heart rate
D) Positioning to increase blood return - Correct Answers -B) Instruct on deep
breathing.
The client is at risk for inadequate oxygenation.
The nurse should consider teaching the client the importance of deep breathing to
increase the amount of oxygen in the body tissues. Clustering activities would
negatively impact oxygenation. Periods of rest should occur between activities. The
client with oxygenation issues will have tachycardia. The nurse should consider
medications that would reduce instead of increase the heart rate. The client should be in
the high-Fowler position to improve oxygenation. Positions to increase blood flow to the
heart would include Trendelenburg, which would negatively impact oxygenation.
3) An older client is diagnosed with cardiomyopathy and a cardiac dysrhythmia. What
would the nurse expect to be indicated for this client?
A) Beta blocker
B) Digoxin
C) Nitrate medications
D) Fluids - Correct Answers -A) Beta blocker
,Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and
antiarrhythmics. Nitrates should be avoided because they increase blood pressure.
Digoxin should be avoided because it increases the force of contractions. The client
should be on a sodium and fluid restriction and not be encouraged to drink fluids.
A client is admitted with complaints of lower extremity edema and occasional shortness
of breath. Which electrocardiogram finding supports that the client is at risk for an
alteration in perfusion?
A) P wave smooth and round
B) Absent U wave
C) PR interval 0.30 seconds
D) ST segment isoelectric - Correct Answers -C) PR interval 0.30 seconds
The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds
indicate a delay in conduction from the SA node to the ventricles. A P wave should be
smooth and round. The ST segment should be isoelectric. The U wave is not normally
seen.
The nurse identifies the diagnosis Ineffective Peripheral Tissue Perfusion related to
decreased arterial flow to extremities as appropriate for a client. What should the nurse
instruct the client to do to improve blood flow?
A) Cross the legs at the knees when seated.
B) Use a heating pad to increase warmth.
C) Elevate the feet while reclining.
D) Position with the extremities dependent. - Correct Answers -D) Position with the
extremities dependent.
Positioning with the extremities dependent is correct because gravity promotes arterial
flow to the dependent extremity, increasing tissue perfusion. Crossing the legs at the
knees when seated is not recommended because this position compresses partially
obstructed arteries and impairs blood flow. Elevating the feet while reclining is not
recommended because elevating the feet works against gravity and will further impede
blood flow. Using a heating pad to increase warmth is not recommended because
external heating devices could increase the risk of burns in a client with impaired
circulation and decreased sensation.
The nurse is planning care for a client with peripheral vascular disease who is at risk for
Impaired Skin Integrity. What would be included in this client's plan of care?
A) Restrict fluids.
B) Keep the skin clean and dry, and moisturize areas of dryness.
C) Encourage bed rest with legs elevated on pillows.
D) Consult a dietitian for low-protein diet. - Correct Answers -B) Keep the skin clean and
dry, and moisturize areas of dryness.
, The client with peripheral vascular disease who is at risk for impaired skin integrity
should have meticulous skin care to keep the skin clean, dry, and well-moisturized to
prevent skin breakdown. A low-protein diet is not beneficial for wound healing and may
not be indicated for this client. A fluid restriction would dry tissues and not promote good
skin turgor. Bed rest with legs elevated on pillows could increase the client's pain and
would not help with preventing skin breakdown.
The nurse is instructing a client on lifestyle changes to prevent the onset of heart
disease. What should be included in this teaching?
Select all that apply.
A) Limit exercise to 15 minutes a day.
B) Reduce saturated fats in the diet.
C) Avoid cigarette smoking.
D) Wear elastic hose.
E) Limit fluid intake. - Correct Answers -B) Reduce saturated fats in the diet.
C) Avoid cigarette smoking.
Interventions that would help the client prevent the onset of cardiovascular disease
would be to avoid cigarette smoking and reduce saturated fats in the diet. Limiting fluids
and wearing elastic hose are not known to prevent the onset of cardiovascular disease.
Fifteen minutes of exercise a day may not be enough exercise to prevent the onset of
cardiovascular disease.
6) An elderly female client complains of fatigue, nausea, intermittent chest discomfort,
and not sleeping well. What should the nurse suspect this client is experiencing?
A) Pancreatic disease
B) Cardiac disease
C) Normal changes of aging
D) Signs of anemia - Correct Answers -B) Cardiac disease
B) Many elderly women complain of vague symptoms when having a myocardial
infarction including fatigue, epigastric pain, and sleep disturbances. Pancreatic disease
would present pain in the abdominal region. These symptoms are not considered
normal changes of aging. Anemia would present with fatigue but not with nausea or
chest discomfort.
7) A client is prescribed metoprolol for a heart disorder. What should the nurse teach
the client about this medication?
A) Expect a rapid heart rate.
B) Change positions slowly.
C) Reduce protein intake.
D) Increase fluids. - Correct Answers -B) Change positions slowly.
1) What will the nurse most likely assess in a client with right heart failure?
A) Leg cramps
B) Indigestion
C) Reduced circulation to the pulmonary structures
D) Reduced urine output - Correct Answers -C) Reduced circulation to the pulmonary
structures
Circulation to the pulmonary structures begins with the right side of the heart. The client
with right heart failure will have reduced circulation to these structures. There is no
evidence to suggest that right heart failure will cause indigestion or reduced urine
output. Not all clients with right heart failure experience leg cramps.
The nurse is concerned that a client with an alteration in perfusion is at risk for
inadequate oxygenation. What should the nurse consider when planning for this client's
potential health problem?
A) Cluster activities.
B) Instruct on deep breathing.
C) Medications appropriate to increase heart rate
D) Positioning to increase blood return - Correct Answers -B) Instruct on deep
breathing.
The client is at risk for inadequate oxygenation.
The nurse should consider teaching the client the importance of deep breathing to
increase the amount of oxygen in the body tissues. Clustering activities would
negatively impact oxygenation. Periods of rest should occur between activities. The
client with oxygenation issues will have tachycardia. The nurse should consider
medications that would reduce instead of increase the heart rate. The client should be in
the high-Fowler position to improve oxygenation. Positions to increase blood flow to the
heart would include Trendelenburg, which would negatively impact oxygenation.
3) An older client is diagnosed with cardiomyopathy and a cardiac dysrhythmia. What
would the nurse expect to be indicated for this client?
A) Beta blocker
B) Digoxin
C) Nitrate medications
D) Fluids - Correct Answers -A) Beta blocker
,Treatment for cardiomyopathy includes calcium channel blockers, beta blockers, and
antiarrhythmics. Nitrates should be avoided because they increase blood pressure.
Digoxin should be avoided because it increases the force of contractions. The client
should be on a sodium and fluid restriction and not be encouraged to drink fluids.
A client is admitted with complaints of lower extremity edema and occasional shortness
of breath. Which electrocardiogram finding supports that the client is at risk for an
alteration in perfusion?
A) P wave smooth and round
B) Absent U wave
C) PR interval 0.30 seconds
D) ST segment isoelectric - Correct Answers -C) PR interval 0.30 seconds
The PR interval is normally 0.12-0.20 seconds. Intervals greater than 0.20 seconds
indicate a delay in conduction from the SA node to the ventricles. A P wave should be
smooth and round. The ST segment should be isoelectric. The U wave is not normally
seen.
The nurse identifies the diagnosis Ineffective Peripheral Tissue Perfusion related to
decreased arterial flow to extremities as appropriate for a client. What should the nurse
instruct the client to do to improve blood flow?
A) Cross the legs at the knees when seated.
B) Use a heating pad to increase warmth.
C) Elevate the feet while reclining.
D) Position with the extremities dependent. - Correct Answers -D) Position with the
extremities dependent.
Positioning with the extremities dependent is correct because gravity promotes arterial
flow to the dependent extremity, increasing tissue perfusion. Crossing the legs at the
knees when seated is not recommended because this position compresses partially
obstructed arteries and impairs blood flow. Elevating the feet while reclining is not
recommended because elevating the feet works against gravity and will further impede
blood flow. Using a heating pad to increase warmth is not recommended because
external heating devices could increase the risk of burns in a client with impaired
circulation and decreased sensation.
The nurse is planning care for a client with peripheral vascular disease who is at risk for
Impaired Skin Integrity. What would be included in this client's plan of care?
A) Restrict fluids.
B) Keep the skin clean and dry, and moisturize areas of dryness.
C) Encourage bed rest with legs elevated on pillows.
D) Consult a dietitian for low-protein diet. - Correct Answers -B) Keep the skin clean and
dry, and moisturize areas of dryness.
, The client with peripheral vascular disease who is at risk for impaired skin integrity
should have meticulous skin care to keep the skin clean, dry, and well-moisturized to
prevent skin breakdown. A low-protein diet is not beneficial for wound healing and may
not be indicated for this client. A fluid restriction would dry tissues and not promote good
skin turgor. Bed rest with legs elevated on pillows could increase the client's pain and
would not help with preventing skin breakdown.
The nurse is instructing a client on lifestyle changes to prevent the onset of heart
disease. What should be included in this teaching?
Select all that apply.
A) Limit exercise to 15 minutes a day.
B) Reduce saturated fats in the diet.
C) Avoid cigarette smoking.
D) Wear elastic hose.
E) Limit fluid intake. - Correct Answers -B) Reduce saturated fats in the diet.
C) Avoid cigarette smoking.
Interventions that would help the client prevent the onset of cardiovascular disease
would be to avoid cigarette smoking and reduce saturated fats in the diet. Limiting fluids
and wearing elastic hose are not known to prevent the onset of cardiovascular disease.
Fifteen minutes of exercise a day may not be enough exercise to prevent the onset of
cardiovascular disease.
6) An elderly female client complains of fatigue, nausea, intermittent chest discomfort,
and not sleeping well. What should the nurse suspect this client is experiencing?
A) Pancreatic disease
B) Cardiac disease
C) Normal changes of aging
D) Signs of anemia - Correct Answers -B) Cardiac disease
B) Many elderly women complain of vague symptoms when having a myocardial
infarction including fatigue, epigastric pain, and sleep disturbances. Pancreatic disease
would present pain in the abdominal region. These symptoms are not considered
normal changes of aging. Anemia would present with fatigue but not with nausea or
chest discomfort.
7) A client is prescribed metoprolol for a heart disorder. What should the nurse teach
the client about this medication?
A) Expect a rapid heart rate.
B) Change positions slowly.
C) Reduce protein intake.
D) Increase fluids. - Correct Answers -B) Change positions slowly.
