DANC 2325 HESI NURSING VERSION ACTUAL EXAM TEST PAPER FULL QUESTIONS
CORRECT RESPONSES
Question:
● 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.
Answer:
2. Pedal pulses. 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. CN: Reduction of risk potential; CL: Analyze
Question:
● 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.- promote circulation by
reducing weight. 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.
Answer:
1. Apply lanolin or petroleum jelly to intact skin. 2. Follow a reduced-calorie, reduced-fat diet.-
promote circulation by reducing weight. 3. Inspect the involved areas daily for new ulcerations. 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. CN: Health promotion and maintenance; CL: Synthesize
,Question:
● 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.".
Answer:
3. "I should stop taking Plavix if it makes me feel weak and dizzy." 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. CN: Pharmacological and parenteral therapies; CL: Evaluate
Question:
● 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.".
Answer:
3. "I am able to walk further without leg pain." 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. CN: Pharmacological and parenteral therapies; CL:
Evaluate
,Question:
● 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.
Answer:
1. Decreased blood flow. 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.
Question:
● 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.
Answer:
1. Decreased blood flow. 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.
Question:
● 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.
Answer:
4. Increased venous pressure. 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. CN: Reduction
of risk potential; CL: Analyze
, Question:
● 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.
Answer:
2. Age. 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.
Question:
● The nurse is assessing the lower extremities of the client with peripheral vascular disease (PVD).
During the assessment, the nurse should expect to find which of the following clinical
manifestations of PVD? Select all that apply. 1. Hairy legs. 2. Mottled skin. 3. Pink skin. 4.
Coolness. 5. Moist skin.
Answer:
2. Mottled skin 4. Coolness. Reduction of blood flow to a specific area results in decreased oxygen
and nutrients. As a result, the skin may appear mottled. The skin will also be cool to the touch. Loss
of hair and dry skin are other signs that the nurse may observe in a client with PVD of the lower
extremities. CN: Health promotion and maintenance; CL: Analyze
Question:
● The nurse is unable to palpate the client's left pedal pulses. Which of the following actions should
the nurse take next? 1. Auscultate the pulses with a stethoscope. 2. Call the physician. 3. Use a
Doppler ultrasound device. 4. Inspect the lower left extremity.
Answer:
3. Use a Doppler ultrasound device. When pedal pulses are not palpable, the nurse should obtain a
Doppler ultrasound device. Auscultation is not likely to be helpful if the pulse isn't palpable.
Inspection of the lower extremity can be done simultaneously when palpating, but the nurse should
first try to locate a pulse by Doppler. Calling the physician may be necessary if there is a change in
the client's condition. CN: Physiological adaptation; CL: Synthesize
CORRECT RESPONSES
Question:
● 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.
Answer:
2. Pedal pulses. 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. CN: Reduction of risk potential; CL: Analyze
Question:
● 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.- promote circulation by
reducing weight. 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.
Answer:
1. Apply lanolin or petroleum jelly to intact skin. 2. Follow a reduced-calorie, reduced-fat diet.-
promote circulation by reducing weight. 3. Inspect the involved areas daily for new ulcerations. 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. CN: Health promotion and maintenance; CL: Synthesize
,Question:
● 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.".
Answer:
3. "I should stop taking Plavix if it makes me feel weak and dizzy." 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. CN: Pharmacological and parenteral therapies; CL: Evaluate
Question:
● 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.".
Answer:
3. "I am able to walk further without leg pain." 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. CN: Pharmacological and parenteral therapies; CL:
Evaluate
,Question:
● 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.
Answer:
1. Decreased blood flow. 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.
Question:
● 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.
Answer:
1. Decreased blood flow. 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.
Question:
● 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.
Answer:
4. Increased venous pressure. 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. CN: Reduction
of risk potential; CL: Analyze
, Question:
● 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.
Answer:
2. Age. 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.
Question:
● The nurse is assessing the lower extremities of the client with peripheral vascular disease (PVD).
During the assessment, the nurse should expect to find which of the following clinical
manifestations of PVD? Select all that apply. 1. Hairy legs. 2. Mottled skin. 3. Pink skin. 4.
Coolness. 5. Moist skin.
Answer:
2. Mottled skin 4. Coolness. Reduction of blood flow to a specific area results in decreased oxygen
and nutrients. As a result, the skin may appear mottled. The skin will also be cool to the touch. Loss
of hair and dry skin are other signs that the nurse may observe in a client with PVD of the lower
extremities. CN: Health promotion and maintenance; CL: Analyze
Question:
● The nurse is unable to palpate the client's left pedal pulses. Which of the following actions should
the nurse take next? 1. Auscultate the pulses with a stethoscope. 2. Call the physician. 3. Use a
Doppler ultrasound device. 4. Inspect the lower left extremity.
Answer:
3. Use a Doppler ultrasound device. When pedal pulses are not palpable, the nurse should obtain a
Doppler ultrasound device. Auscultation is not likely to be helpful if the pulse isn't palpable.
Inspection of the lower extremity can be done simultaneously when palpating, but the nurse should
first try to locate a pulse by Doppler. Calling the physician may be necessary if there is a change in
the client's condition. CN: Physiological adaptation; CL: Synthesize
