Med Surg 2021 Hesi practice
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The nurse is assessing a 48-year-old client with a history of
smoking during a
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routine clinic visit. The client, who exercises regularly, reports
having pain in the calf
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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. Ans: 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
, 2
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
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arterial blood flow. What should the nurse instruct the client to
do? Select all that apply.
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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 Ans: 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
, 3
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
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consult an exercise
physiologist for an exercise program that enhances the aerobic
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capacity of the body.
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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 Ans: 2
With each set of vital signs, the nurse should assess the
dorsalis pedis and
, 4
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
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graft is maintained.
The nurse is caring for a client with peripheral artery disease
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who has recently
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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."