Chapter 33: Concepts of Care for Patients
with Vascular Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A client had a femoral-popliteal bypass graft with a synthetic graft. What action by the
nurse is most important to prevent wound infection?
a. Appropriate hand hygiene before giving care
b. Assessing the client’s temperature every 4 hours
c. Clean technique when changing dressings
d. Monitoring the client’s daily white blood cell count
ANS: A
Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing
changes would be done with sterile technique. Assessing vital signs and white blood
cell count will not prevent infection.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: Infection control, Hand hygiene MSC:
Client Needs Category: Safe and Effective Care Environment: Safety and
Infection Control
2. A client is receiving an infusion of alteplase for an intra-arterial clot. The client begins
to mumble and is disoriented. What action by the nurse is most important?
a. Assess the client’s neurologic status.
b. Notify the Rapid Response Team.
c. Prepare to administer vitamin K.
, d. Turn down the infusion rate.
ANS: B
Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of
neurologic signs may indicate that the client is having a hemorrhagic stroke. The
nurse does need to complete a thorough neurologic examination, but would first call
the Rapid Response Team based on the client’s manifestations. Vitamin K is not the
antidote for this drug. Turning down the infusion rate will not be helpful if the client
is still receiving any of the drug.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: Critical rescue, Fibrinolytic agents MSC:
Client Needs Category: Safe and Effective Care Environment: Management of
Care
3. A new nurse is caring for a client with an abdominal aneurysm. What action by the
new nurse requires the nurse’s mentor to intervene?
a. Assesses the client for back pain.
b. Auscultates over abdominal bruit.
c. Measures the abdominal girth.
d. Palpates the abdomen in four quadrants.
ANS: D
Abdominal aneurysms should never be palpated as this increases the risk of rupture.
The nurse mentoring the new nurse would intervene when the new nurse attempts to
do this. The other actions are appropriate.
DIF: Applying TOP: Integrated Process: Communication and Documentation
KEY: Aneurysms, Abdominal assessment MSC: Client Needs
Category: Safe and Effective Care Environment: Safety and Infection Control
, 4. A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing
assessment indicates that an important outcome has been met?
a. Ambulates with assistance
b. Oxygen saturation of 98%
c. Pain of 2/10 after medication
d. Verbalizing risk factors
ANS: B
A critical complication of DVT is pulmonary embolism. A normal oxygen saturation
indicates that this has not occurred. The other assessments are also positive, but not as
important.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment
KEY: Pulmonary embolism, Nursing assessment MSC: Client
Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A client has a deep vein thrombosis (DVT). What comfort measure does the nurse
delegate to the assistive personnel (AP)?
a. Ambulate the client.
b. Apply a warm moist pack.
c. Massage the client’s leg.
d. Provide an ice pack.
ANS: B
Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort
measure. Massaging the client’s legs is contraindicated to prevent complications such
as pulmonary embolism. Ice packs are not recommended for DVT.
DIF: Understanding TOP: Integrated Process: Communication and
Documentation KEY: Thromboembolic event, Comfort measures
MSC: Client Needs Category: Physiological Integrity: Basic Care and
Comfort
with Vascular Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A client had a femoral-popliteal bypass graft with a synthetic graft. What action by the
nurse is most important to prevent wound infection?
a. Appropriate hand hygiene before giving care
b. Assessing the client’s temperature every 4 hours
c. Clean technique when changing dressings
d. Monitoring the client’s daily white blood cell count
ANS: A
Hand hygiene is the best way to prevent infections in hospitalized clients. Dressing
changes would be done with sterile technique. Assessing vital signs and white blood
cell count will not prevent infection.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: Infection control, Hand hygiene MSC:
Client Needs Category: Safe and Effective Care Environment: Safety and
Infection Control
2. A client is receiving an infusion of alteplase for an intra-arterial clot. The client begins
to mumble and is disoriented. What action by the nurse is most important?
a. Assess the client’s neurologic status.
b. Notify the Rapid Response Team.
c. Prepare to administer vitamin K.
, d. Turn down the infusion rate.
ANS: B
Clients on fibrinolytic therapy are at high risk of bleeding. The sudden onset of
neurologic signs may indicate that the client is having a hemorrhagic stroke. The
nurse does need to complete a thorough neurologic examination, but would first call
the Rapid Response Team based on the client’s manifestations. Vitamin K is not the
antidote for this drug. Turning down the infusion rate will not be helpful if the client
is still receiving any of the drug.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: Critical rescue, Fibrinolytic agents MSC:
Client Needs Category: Safe and Effective Care Environment: Management of
Care
3. A new nurse is caring for a client with an abdominal aneurysm. What action by the
new nurse requires the nurse’s mentor to intervene?
a. Assesses the client for back pain.
b. Auscultates over abdominal bruit.
c. Measures the abdominal girth.
d. Palpates the abdomen in four quadrants.
ANS: D
Abdominal aneurysms should never be palpated as this increases the risk of rupture.
The nurse mentoring the new nurse would intervene when the new nurse attempts to
do this. The other actions are appropriate.
DIF: Applying TOP: Integrated Process: Communication and Documentation
KEY: Aneurysms, Abdominal assessment MSC: Client Needs
Category: Safe and Effective Care Environment: Safety and Infection Control
, 4. A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing
assessment indicates that an important outcome has been met?
a. Ambulates with assistance
b. Oxygen saturation of 98%
c. Pain of 2/10 after medication
d. Verbalizing risk factors
ANS: B
A critical complication of DVT is pulmonary embolism. A normal oxygen saturation
indicates that this has not occurred. The other assessments are also positive, but not as
important.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Assessment
KEY: Pulmonary embolism, Nursing assessment MSC: Client
Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A client has a deep vein thrombosis (DVT). What comfort measure does the nurse
delegate to the assistive personnel (AP)?
a. Ambulate the client.
b. Apply a warm moist pack.
c. Massage the client’s leg.
d. Provide an ice pack.
ANS: B
Warm moist packs will help with the pain of a DVT. Ambulation is not a comfort
measure. Massaging the client’s legs is contraindicated to prevent complications such
as pulmonary embolism. Ice packs are not recommended for DVT.
DIF: Understanding TOP: Integrated Process: Communication and
Documentation KEY: Thromboembolic event, Comfort measures
MSC: Client Needs Category: Physiological Integrity: Basic Care and
Comfort
