NURS 435 EXAM 2 QUESTIONS AND ANSWERS STUDY GUIDE
WITH COMPLETE SOLUTION!!
Which risk factor should the nurse focus on when teaching a patient who has a 5-
cm abdominal aortic aneurysm?
Answers :Answer: Uncontrolled hypertension
Which finding on a patient's nursing admission assessment is congruent with the
initial medical diagnosis of a 6-cm thoracic aortic aneurysm?
Answers :Answer: trouble swallowing
Rationale: Difficulty swallowing may occur with a thoracic aneurysm because of
pressure on the esophagus. The other symptoms will be important to assess for in
patients with abdominal aortic aneurysms.
Several hours after a patient had an open surgical repair of an abdominal aortic
aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has
been 45 mL. What should the nurse anticipate will be prescribed?
Answers :Answer: increased IV fluids
Rationale: The decreased urine output suggests decreased renal perfusion and
monitoring of renal function is needed. There is no indication that infection is a
concern, so antibiotic therapy and a WBC count are not needed. The IV rate may
be increased because hypovolemia may be contributing to the patient's decreased
urinary output.
Which group of drugs will the nurse plan to include when teaching a patient who
has a new diagnosis of peripheral artery disease (PAD)?
,Answers :Answer: Statins
Rationale: Research indicates that statin use by patients with PAD improves
multiple outcomes. There is no research that supports the use of the other drug
categories in PAD.
An older patient with chronic atrial fibrillation develops sudden severe pain,
pulselessness, pallor, and coolness in the right leg. After the nurse notifies the
health care provider, what should the nurse do next?
Answers :Answer: Keep the patient in bed in the supine position
Rationale: The patient's history and clinical manifestations are consistent with
acute arterial occlusion. Resting the leg will decrease the O2 demand of the tissues
and minimize ischemic damage until circulation can be restored. Elevating the leg
or applying an elastic wrap will further compromise blood flow to the leg. Exercise
will increase oxygen demand for the tissues of the
leg.
A patient at the clinic says, "I always walk after dinner, but lately my leg cramps
and hurts after just a few minutes. The pain goes away after I stop walking,
though." What focused assessment should the nurse make?
Answers :Answer: Palpate the presence of dosrsalis pedis and posterior tibial
pulses
Rationale: The nurse should assess for other clinical manifestations of peripheral
arterial disease in a patient who describes intermittent claudication. Changes in
skin color that occur in response to cold are consistent with Raynaud's
phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral
leg swelling, redness, and tenderness indicate venous thromboembolism.
A patient has chronic peripheral artery disease (PAD) of the legs and an ulcer on
the right second toe. What should the nurse expect to find on assessment?
,Answers :Answer: Prolonged capillary refill in all the toes
Rationale: Capillary refill is prolonged in PAD because of the slower and
decreased blood flow to the periphery. The other listed clinical manifestations are
consistent with chronic venous disease.
The nurse is evaluating the discharge teaching outcomes for a patient with chronic
peripheral artery disease (PAD). Which patient statement indicates a need for
further instruction?
Answers :Answer: "I will use a heating pad on my feet at night to increase the
circulation."
Rationale: Because the patient has impaired circulation and sensation to the feet,
the use of a heating pad could lead to burns. The other patient statements are
correct and indicate that teaching has been successful.
Which action by the patient with newly diagnosed Raynaud's phenomenon best
demonstrates that the nurse's teaching about managing the condition has been
effective?
Answers :Answer: The patient exercises indoors during the winter months.
Rationale: Patients should avoid temperature extremes by exercising indoors when
it is cold. To avoid burn injuries, the patient should use warm rather than hot water
to warm the hands. Pseudoephedrine is a vasoconstrictor and should be avoided.
There is no reason to avoid taking NSAIDs with Raynaud's phenomenon.
The health care provider has prescribed bed rest with the feet elevated for a patient
admitted to the hospital with venous thromboembolism of the left lower leg. Which
action by the nurse is best?
, Answers :Answer: One pillow is placed under the thighs and 2 pillows are under
the lower legs.
Rationale: The purpose of elevating the feet is to enhance venous flow from the
feet to the right atrium, which is best accomplished by placing 2 pillows under the
feet and another under the thighs. Placing the patient in the Trendelenburg position
will lower the head below heart level, which is not indicated for this patient.
Placing pillows under the calf or elevating the bed at the knee may cause blood
stasis at the calf level.
The health care provider prescribes an infusion of heparin and daily partial
thromboplastin time (PTT) testing for a patient with venous thromboembolism
(VTE). Which action should the nurse include in the plan of care?
Answers :Answer: Avoid giving IM medications to prevent localized bleeding.
Rationale: Intramuscular injections are avoided in patients receiving
anticoagulation to prevent hematoma formation and bleeding from the site. A PTT
of 65 seconds is within the therapeutic range. Vitamin K is used to reverse
warfarin. Pulse quality is not affected by VTE.
A patient with a venous thromboembolism (VTE) is started on enoxaparin
(Lovenox) and warfarin (Coumadin). The patient asks the nurse why two
medications are necessary. Which response by the nurse is accurate?
Answers :Answer: "Enoxaparin will work right away, but warfarin takes several
days to begin preventing clots."
Rationale: Low-molecular-weight heparin (LMWH) is used because of the
immediate effect on coagulation and discontinued once the international
normalized ratio (INR) value indicates that the warfarin has reached a therapeutic
level. LMWH has no thrombolytic properties. The use of two anticoagulants is not
related to the risk for pulmonary embolism, and two are not necessary to reduce the
risk for another VTE. Anticoagulants do not thin the blood.
WITH COMPLETE SOLUTION!!
Which risk factor should the nurse focus on when teaching a patient who has a 5-
cm abdominal aortic aneurysm?
Answers :Answer: Uncontrolled hypertension
Which finding on a patient's nursing admission assessment is congruent with the
initial medical diagnosis of a 6-cm thoracic aortic aneurysm?
Answers :Answer: trouble swallowing
Rationale: Difficulty swallowing may occur with a thoracic aneurysm because of
pressure on the esophagus. The other symptoms will be important to assess for in
patients with abdominal aortic aneurysms.
Several hours after a patient had an open surgical repair of an abdominal aortic
aneurysm, the UAP reports to the nurse that urinary output for the past 2 hours has
been 45 mL. What should the nurse anticipate will be prescribed?
Answers :Answer: increased IV fluids
Rationale: The decreased urine output suggests decreased renal perfusion and
monitoring of renal function is needed. There is no indication that infection is a
concern, so antibiotic therapy and a WBC count are not needed. The IV rate may
be increased because hypovolemia may be contributing to the patient's decreased
urinary output.
Which group of drugs will the nurse plan to include when teaching a patient who
has a new diagnosis of peripheral artery disease (PAD)?
,Answers :Answer: Statins
Rationale: Research indicates that statin use by patients with PAD improves
multiple outcomes. There is no research that supports the use of the other drug
categories in PAD.
An older patient with chronic atrial fibrillation develops sudden severe pain,
pulselessness, pallor, and coolness in the right leg. After the nurse notifies the
health care provider, what should the nurse do next?
Answers :Answer: Keep the patient in bed in the supine position
Rationale: The patient's history and clinical manifestations are consistent with
acute arterial occlusion. Resting the leg will decrease the O2 demand of the tissues
and minimize ischemic damage until circulation can be restored. Elevating the leg
or applying an elastic wrap will further compromise blood flow to the leg. Exercise
will increase oxygen demand for the tissues of the
leg.
A patient at the clinic says, "I always walk after dinner, but lately my leg cramps
and hurts after just a few minutes. The pain goes away after I stop walking,
though." What focused assessment should the nurse make?
Answers :Answer: Palpate the presence of dosrsalis pedis and posterior tibial
pulses
Rationale: The nurse should assess for other clinical manifestations of peripheral
arterial disease in a patient who describes intermittent claudication. Changes in
skin color that occur in response to cold are consistent with Raynaud's
phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral
leg swelling, redness, and tenderness indicate venous thromboembolism.
A patient has chronic peripheral artery disease (PAD) of the legs and an ulcer on
the right second toe. What should the nurse expect to find on assessment?
,Answers :Answer: Prolonged capillary refill in all the toes
Rationale: Capillary refill is prolonged in PAD because of the slower and
decreased blood flow to the periphery. The other listed clinical manifestations are
consistent with chronic venous disease.
The nurse is evaluating the discharge teaching outcomes for a patient with chronic
peripheral artery disease (PAD). Which patient statement indicates a need for
further instruction?
Answers :Answer: "I will use a heating pad on my feet at night to increase the
circulation."
Rationale: Because the patient has impaired circulation and sensation to the feet,
the use of a heating pad could lead to burns. The other patient statements are
correct and indicate that teaching has been successful.
Which action by the patient with newly diagnosed Raynaud's phenomenon best
demonstrates that the nurse's teaching about managing the condition has been
effective?
Answers :Answer: The patient exercises indoors during the winter months.
Rationale: Patients should avoid temperature extremes by exercising indoors when
it is cold. To avoid burn injuries, the patient should use warm rather than hot water
to warm the hands. Pseudoephedrine is a vasoconstrictor and should be avoided.
There is no reason to avoid taking NSAIDs with Raynaud's phenomenon.
The health care provider has prescribed bed rest with the feet elevated for a patient
admitted to the hospital with venous thromboembolism of the left lower leg. Which
action by the nurse is best?
, Answers :Answer: One pillow is placed under the thighs and 2 pillows are under
the lower legs.
Rationale: The purpose of elevating the feet is to enhance venous flow from the
feet to the right atrium, which is best accomplished by placing 2 pillows under the
feet and another under the thighs. Placing the patient in the Trendelenburg position
will lower the head below heart level, which is not indicated for this patient.
Placing pillows under the calf or elevating the bed at the knee may cause blood
stasis at the calf level.
The health care provider prescribes an infusion of heparin and daily partial
thromboplastin time (PTT) testing for a patient with venous thromboembolism
(VTE). Which action should the nurse include in the plan of care?
Answers :Answer: Avoid giving IM medications to prevent localized bleeding.
Rationale: Intramuscular injections are avoided in patients receiving
anticoagulation to prevent hematoma formation and bleeding from the site. A PTT
of 65 seconds is within the therapeutic range. Vitamin K is used to reverse
warfarin. Pulse quality is not affected by VTE.
A patient with a venous thromboembolism (VTE) is started on enoxaparin
(Lovenox) and warfarin (Coumadin). The patient asks the nurse why two
medications are necessary. Which response by the nurse is accurate?
Answers :Answer: "Enoxaparin will work right away, but warfarin takes several
days to begin preventing clots."
Rationale: Low-molecular-weight heparin (LMWH) is used because of the
immediate effect on coagulation and discontinued once the international
normalized ratio (INR) value indicates that the warfarin has reached a therapeutic
level. LMWH has no thrombolytic properties. The use of two anticoagulants is not
related to the risk for pulmonary embolism, and two are not necessary to reduce the
risk for another VTE. Anticoagulants do not thin the blood.
