Tif32

LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test
Bank
Chapter 32
Question 1
Type: MCSA
The nurse measures a patient’s blood pressure as 144/88 mmHg. What intervention would be most appropriate for
this patient?
1. Provide stress-reduction techniques.
2. Inform the physician so antihypertensive medication can be prescribed.
3. Offer the patient a glass of water.
4. Remeasure the blood pressure in a few minutes.
Correct Answer: 4
Rationale 1: The patient may not feel stressed.
Rationale 2: The patient may not need antihypertensive medication.
Rationale 3: Offering a glass of water would have no effect on the blood pressure.
Rationale 4: There is no evidence that this patient has had previously high blood pressure readings. The nurse
should remeasure the blood pressure in a few minutes in the event the reading was because of physical activity or
anxiety. Hypertension is defined as systolic blood pressure of 140 mmHg or higher, or diastolic pressure of 90
mmHg or higher, based on the average of three or more readings taken on separate occasions.
Global Rationale: There is no evidence that this patient has had previously high blood pressure readings. The
nurse should remeasure the blood pressure in a few minutes in the event the reading was because of physical
activity or anxiety. Hypertension is defined as systolic blood pressure of 140 mmHg or higher, or diastolic
pressure of 90 mmHg or higher, based on the average of three or more readings taken on separate occasions. The
patient may not feel stressed or need anti-hypertensive medication. Offering a glass of water would have no effect
on the blood pressure.
Cognitive Level: Applying

Client Need: Health Promotion and Maintenance
Client Need Sub:
QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank
Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological,
spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using
developmentally and culturally appropriate approaches
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health
assessments and interventions
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. Compare and contrast the manifestations and effects of disorders affecting large and small
vessels, arteries, and veins.
MNL Learning Outcome: 6.1.1. Explain the incidence, risk factors, and pathophysiology for disorders of blood
pressure regulation.
Page Number: 968
Question 2
Type: MCSA
A patient with diabetes is beginning treatment for hypertension. What should the nurse explain as being the blood
pressure treatment goal for this patient?
1. 140/90 mmHg
2. 135/85 mmHg
3. 130/80 mmHg
4. 120/80 mmHg
Correct Answer: 3
Rationale 1: Hypertension management focuses on reducing the blood pressure to less than 140 mmHg systolic
and 90 mmHg diastolic.
Rationale 2: This is incorrect.
Rationale 3: The risk of cardiovascular complications decreases when the average blood pressure is less than
140/90; when the patient also has diabetes or renal disease, the treatment goal is a blood pressure less than 130/80.
Rationale 4: When the patient also has diabetes or renal disease, the treatment goal is a blood pressure less than
130/80.
Global Rationale: Hypertension management focuses on reducing the blood pressure to less than 140 mmHg
systolic and 90 mmHg diastolic. The ultimate goal of hypertension management is to reduce cardiovascular and
renal morbidity and mortality. The risk of cardiovascular complications decreases when the average blood
pressure is less than 140/90; when the patient also has diabetes or renal disease, the treatment goal is a blood
pressure less than 130/80.
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for
managing the acute and chronic care of patients and promoting health across the lifespan
Learning Outcome: 2. Explain risk factors for and measures to prevent peripheral vascular disorders and their
complications.
MNL Learning Outcome: 6.1.3. Examine the treatment options for disorders of blood pressure regulation.
Page Number: 971
Question 3
Type: MCMA
The nurse is instructing a patient with hypertension about lifestyle modifications. What would be appropriate to
include in the teaching for this patient?
Standard Text: Select all that apply.
1. Review the DASH diet.
2. Begin a walking program, and progress to 30 minutes 5 to 6 days each week.
3. Plan a weight lifting regimen.
4. Eliminate dairy products from the diet.
5. Restrict fluid intake.
Correct Answer: 1, 2
Rationale 1: Dietary approaches to managing hypertension focus on reducing sodium intake, maintaining
adequate potassium and calcium intakes, and reducing total and saturated fat intake. The DASH diet has proven
beneficial effects in lowering blood pressure.
Rationale 2: Regular exercise reduces blood pressure and contributes to weight loss, stress reduction, and feelings
of overall well-being. Previously sedentary patients are encouraged to engage in aerobic exercise for 30 to 45
minutes per day most days of the week.

Rationale 3: Isometric exercise, such as weight training, may not be appropriate, as it can raise the systolic blood
pressure.
Rationale 4: Dietary approaches to managing hypertension focus on reducing sodium intake, maintaining
adequate potassium and calcium intakes, and reducing total and saturated fat intake.
Rationale 5: Fluid restriction is not indicated.
Global Rationale: Lifestyle modifications are recommended for all patients whose blood pressure falls within the
prehypertension range and everyone with intermittent or sustained hypertension. These modifications include
weight loss, dietary changes, restricted alcohol use and cigarette smoking, increased physical activity, and stress
reduction. Dietary approaches to managing hypertension focus on reducing sodium intake, maintaining adequate
potassium and calcium intakes, and reducing total and saturated fat intake. The DASH diet has proven beneficial
effects in lowering blood pressure. Regular exercise reduces blood pressure and contributes to weight loss, stress
reduction, and feelings of overall well-being. Previously sedentary patients are encouraged to engage in aerobic
exercise for 30 to 45 minutes per day most days of the week. Isometric exercise, such as weight training, may not
be appropriate, as it can raise the systolic blood pressure.

Client Need Sub:
AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage,
age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in
their care
complications.
Page Number: 972

Question 4
Type: MCSA
A patient’s blood pressure continues to be elevated despite being prescribed an ACE inhibitor for several weeks.
What should the nurse do at this time?
1. Ask if the patient is taking the prescribed medication.
2. Suggest to the physician that another medication be added.
3. Schedule the patient to have the blood pressure checked again in a week.

4. Realize the patient is anxious because of the diagnosis.
Correct Answer: 1
Rationale 1: Noncompliance, or failure to follow the identified treatment plan, is a continuing risk for any patient
with a chronic disease. Prescribed medications may have undesirable effects, whereas hypertension itself often
has no symptoms or noticeable effects. The nurse should inquire about reasons for noncompliance with the
recommended treatment plan by assessing for factors that can contribute to noncompliance, such as adverse drug
effects. If it is determined that the patient is not taking the prescribed medication, the other interventions would
not be indicated at this time.
Rationale 2: Further assessment is indicated prior to this intervention.
Rationale 3: Further assessment is indicated prior to this intervention.
Rationale 4: There is no evidence of the patient being anxious because of the diagnosis.
Global Rationale: Noncompliance, or failure to follow the identified treatment plan, is a continuing risk for any
patient with a chronic disease. Prescribed medications may have undesirable effects, whereas hypertension itself
often has no symptoms or noticeable effects. The nurse should inquire about reasons for noncompliance with the
recommended treatment plan by assessing for factors that can contribute to noncompliance, such as adverse drug
effects. If it is determined that the patient is not taking the prescribed medication, the other interventions would
not be indicated at this time.

Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Explain the nursing implications for medications and other interprofessional treatments
used for patients with peripheral vascular disorders.
Page Number: 977
Question 5
Type: MCSA
During the abdominal assessment of an elderly patient, the nurse palpates a mass in the midabdomen. What
should the nurse do next?

1. Percuss the mass.
2. Ask the patient to cough.
3. Get the physician.
4. Auscultate the mass.
Correct Answer: 4
Rationale 1: If an aneurysm were suspected, percussing the mass would be inappropriate because it could
increase the pressure on the weakened site.
Rationale 2: If an aneurysm were suspected, asking the patient to cough is inappropriate because it could increase
the pressure on the weakened site.
Rationale 3: Further assessment is needed before contacting the physician.
Rationale 4: Most abdominal aneurysms are asymptomatic, but a pulsating mass in the mid- and upper abdomen
and a bruit (the sound auscultated over turbulent or restricted blood flow) over the mass are found on exam.
Global Rationale: Further assessment is needed before the physician would be contacted, typically first by
phone. Most abdominal aneurysms are asymptomatic, but a pulsating mass in the mid- and upper abdomen and a
bruit (the sound auscultated over turbulent or restricted blood flow) over the mass are found on exam. If an
aneurysm were suspected, asking the patient to cough and percussing the mass would be inappropriate responses
that could increase the pressure on the weakened site.

MNL Learning Outcome: 6.6.2. Differentiate the manifestations and complications of an aneurysm.
Page Number: 982, 986
Question 6
Type: MCMA

The nurse suspects a patient recovering from an abdominal aortic aneurysm repair is experiencing graft leaking.
What findings did the nurse use to make this clinical decision?
1. urine output 45 mL/hr
2. complaint of groin pain
3. abdominal dressing dry and intact
4. respiratory rate 16 and regular
5. complaint of back discomfort
Rationale 1: The nurse would not report the output unless it was less than 30mL/hour.
Rationale 2: The nurse should monitor for and report groin pain.
Rationale 3: A dry and intact abdominal dressing is a normal finding.
Rationale 4: A respiratory rate of 16 and regular is a normal finding.
Rationale 5: The nurse should monitor for and report any back pain.
Global Rationale: The nurse should monitor for and report any back, or groin pain. The urine output needs to be
below 30 mL/hr before reporting. A dry abdominal dressing and respiratory rate of 16 and regular are expected
findings.
Cognitive Level: Analyzing

Learning Outcome: 4. Describe preoperative and postoperative nursing care of patients having vascular surgery.
MNL Learning Outcome: 6.6.3. Examine the diagnosis and treatment of an aneurysm.
Page Number: 985

Question 7
Type: MCSA
The nurse suspects that a patient is experiencing the effects of peripheral atherosclerosis. What did the nurse most
likely assess in this patient?
1. rubor with extremity elevation
2. normal hair distribution bilaterally over lower extremities
3. peripheral pulses present bilaterally
4. complaints of leg pain upon rest
Correct Answer: 4
Rationale 1: Manifestations of peripheral atherosclerosis include pallor with extremity elevation and rubor with
extremities in dependent position.
Rationale 2: Manifestations of peripheral atherosclerosis include thin, shiny, hairless skin.
Rationale 3: Manifestations of peripheral atherosclerosis include diminished or absent peripheral pulses.
Rationale 4: Manifestations of peripheral atherosclerosis include intermittent claudication; pain at rest;

paresthesias; diminished or absent peripheral pulses; pallor with extremity elevation; rubor with extremities in
dependent position; thin, shiny, hairless skin; thickened toenails; and areas of skin discoloration or skin
breakdown.
Global Rationale: Manifestations of peripheral atherosclerosis include intermittent claudication; pain at rest;
paresthesias; diminished or absent peripheral pulses; pallor with extremity elevation; rubor with extremities in
dependent position; thin, shiny, hairless skin; thickened toenails; and areas of skin discoloration or skin
breakdown.

Client Need Sub: Physiological Adaptation

MNL Learning Outcome: 6.3.1. Explain the incidence, risk factors, and pathophysiology for arterial and venous
occlusive diseases.
Page Number: 988
Question 8
Type: MCSA
A patient is having segmental pressure measurements conducted to help diagnose peripheral vascular disease.
What finding would indicate the presence of this disorder?
1. thigh pressure higher than the arm
2. calf pressure higher than the arm
3. calf pressure lower than the arm
4. no difference between the arm or leg
Correct Answer: 3
Rationale 1: In peripheral vascular disease (PVD), the thigh pressure is not higher than the arm.
Rationale 2: In peripheral vascular disease (PVD), the calf pressure is not higher than the arm.
Rationale 3: Noninvasive studies often are sufficient to diagnose peripheral vascular disease. Segmental pressure
measurements use sphygmomanometer cuffs and a Doppler device to compare blood pressures between the upper
and lower extremities and within different segments of the affected extremity. In peripheral vascular disease
(PVD), the blood pressure may be lower in the legs than in the arms.
Rationale 4: In peripheral vascular disease (PVD), there is a difference between arm and leg blood pressure.
Global Rationale: Noninvasive studies often are sufficient to diagnose peripheral vascular disease. Segmental
pressure measurements use sphygmomanometer cuffs and a Doppler device to compare blood pressures between
the upper and lower extremities and within different segments of the affected extremity. In peripheral vascular
disease (PVD), the blood pressure may be lower in the legs than in the arms.


Learning Outcome: 5. Relate the manifestations and diagnostic test results to the etiology and pathophysiology
of common peripheral vascular and lymphatic disorders.
MNL Learning Outcome: 6.3.2. Differentiate the manifestations and diagnostic tests for arterial and venous
occlusive diseases.
Page Number: 988
Question 9
Type: MCSA
A patient is demonstrating signs of ineffective peripheral tissue perfusion. What intervention would be
appropriate for this patient?
1. Encourage patient to reduce level of exercise.
2. Discuss smoking cessation techniques.
3. Keep extremities cool.
4. Assist with pillow placement under knees.
Correct Answer: 2
Rationale 1: Interventions for a patient who is experiencing ineffective peripheral tissue perfusion include
discussing the benefits of regular exercise.
instructing the patient to avoid smoking. Nicotine is a potent vasoconstrictor that further impairs arterial blood
flow.
keeping extremities warm and avoiding electric heating pads or hot water bottles.
instructing to avoid crossing legs or using a pillow under the knees.
Global Rationale: Interventions for a patient who is experiencing ineffective peripheral tissue perfusion include
instructing the patient to avoid smoking. Nicotine is a potent vasoconstrictor that further impairs arterial blood
flow. The patient should be instructed on the benefits of regular exercise; the importance of keeping the
extremities warm but avoid using electronic heating pads or hot water bottles; and avoiding crossing legs or using
a pillow under the knees.

AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage,
their care
MNL Learning Outcome: 6.3.4. Utilize the nursing process in care of client.
Page Number: 990
Question 10
Type: MCSA
A patient is diagnosed with thromboangiitis obliterans. What would be appropriate teaching for this patient?
1. Medications are the only cure.
2. Surgical procedures can be performed to cure this disorder.
3. Management depends upon the patient’s willingness to stop smoking.
4. Nothing can help manage this disorder.
Correct Answer: 3
Rationale 1: Medications do not cure this disorder.
Rationale 2: Surgical procedures to not cure this disorder.
Rationale 3: The prognosis for thromboangiitis obliterans depends significantly on the patient’s ability and
willingness to stop smoking. With smoking cessation and good foot care, the prognosis for saving the extremities
is good, even though no cure is available.
Rationale 4: With smoking cessation and good foot care, the prognosis for saving the extremities is good, even
though no cure is available.
Global Rationale: The prognosis for thromboangiitis obliterans depends significantly on the patient’s ability and
willingness to stop smoking. With smoking cessation and good foot care, the prognosis for saving the extremities
is good, even though no cure is available.

their care
complications.
occlusive diseases.
Page Number: 992
Question 11
Type: MCSA
A patient is being discharged on long-term oral anticoagulant therapy for arterial thrombus formation in the lower
extremity. What should be included in this patient’s discharge instructions?
1. Slight bleeding from the nose is expected.
2. Contact the physician’s office for follow-up laboratory studies.
3. Pain in the limb is a sign of healing.
4. Take two doses of the prescribed anticoagulant if a dose is missed one day.
Correct Answer: 2
Rationale 1: Nasal bleeding is not expected.
Rationale 2: When preparing the patient and family for home or community-based care related to an acute arterial
occlusion, the patient should be instructed to follow-up with laboratory testing and appointments.
Rationale 3: Pain in the limb could indicate another clot has formed.
Rationale 4: Anticoagulant medications should never be “doubled” even in the case of a missed dose. The patient
would be encouraged to notify the physician if a dose is missed.
Global Rationale: When preparing the patient and family for home or community-based care related to an acute
arterial occlusion, the patient should be instructed to follow-up with laboratory testing and appointments. Nasal

bleeding is not expected. Pain in the limb could indicate another clot has formed. Anticoagulant medications
should never be “doubled” even in the case of a missed dose. The patient would be encouraged to notify the
physician if a dose is missed.

their care
Page Number: 996
Question 12
Type: MCMA
A patient is demonstrating signs of thrombophlebitis. With this disorder, the nurse realizes that three mechanisms
occur, which include:
1. pooling of blood in the vessel.
2. blood hypercoagulation.
3. stasis of blood flow.
4. elevated systemic blood pressure.
5. vessel damage.
Correct Answer: 2, 3, 5
Rationale 1: Blood does not pool in the vessel; it is restricted.
Rationale 2: Three pathologic factors, called Virchow’s triad, are associated with thrombophlebitis. One
pathologic factor is blood coagulability.

pathologic factor is stasis of blood.
Rationale 4: Systemic blood pressure elevation is not a mechanism of this problem.
pathologic factor is vessel damage.
Global Rationale: Three pathologic factors, called Virchow’s triad, are associated with thrombophlebitis: stasis
of blood, vessel damage, and increased blood coagulability. Blood does not pool in the vessel; it is restricted.
Systemic blood pressure elevation is not a mechanism of this problem.

occlusive diseases.
Page Number: 997
Question 13
Type: MCSA
A patient is seen for increasing edema in his left lower extremity and pain in the limb with ambulation. What
should the nurse suspect is occurring in this patient?
1. arterial occlusion
2. deep vein thrombosis
3. superficial vein thrombosis
4. varicose veins
Correct Answer: 2
Rationale 1: These manifestations are not associated with an arterial occlusion.

Rationale 2: The manifestations of deep vein thrombosis (DVT) are primarily due to the inflammatory process
that accompanies the thrombus. Calf pain is the most common symptom, and it may be described as tightness or a
dull, aching pain in the affected extremity, particularly upon walking.
Rationale 3: These are not manifestations of a superficial venous thrombosis.
Rationale 4: Varicose veins are tortuous veins with valve insufficiency.
Global Rationale: The manifestations of deep vein thrombosis (DVT) are primarily due to the inflammatory
process that accompanies the thrombus. Calf pain is the most common symptom, and it may be described as
tightness or a dull, aching pain in the affected extremity, particularly upon walking. A DVT is not an arterial or a
primary superficial vein problem. Varicose veins are tortuous veins with valve insufficiency.

occlusive diseases.
Page Number: 997
Question 14
Type: MCSA
A patient with a deep vein thrombosis (DVT) is going to be weaned from intravenous heparin. When should the
nurse anticipate that oral warfarin sodium would be prescribed?
1. the same day the heparin is discontinued
2. the day before the heparin is discontinued
3. four to five days before the heparin is discontinued
4. the same day as the heparin is started
Correct Answer: 3

Rationale 1: Oral warfarin sodium will not be prescribed the same day the heparin is discontinued.
Rationale 2: Oral warfarin sodium will not be prescribed the day before the heparin is discontinued.
Rationale 3: Oral anticoagulation with warfarin may be initiated concurrently with heparin therapy. Overlapping
heparin and warfarin therapy for four to five days is important because the full anticoagulant effect of warfarin is
delayed, and it may actually promote clotting during the first few days of therapy.
Rationale 4: Oral warfarin sodium will not be prescribed the same day the heparin is started.
Global Rationale: Oral anticoagulation with warfarin may be initiated concurrently with heparin therapy.
Overlapping heparin and warfarin therapy for four to five days is important because the full anticoagulant effect
of warfarin is delayed, and it may actually promote clotting during the first few days of therapy.

Client Need Sub: Pharmacological and Parenteral Therapies
Nursing/Integrated Concepts: Nursing Process: Planning
MNL Learning Outcome: 6.3.3. Examine the treatment options for arterial and venous occlusive diseases.
Page Number: 999
Question 15
Type: MCSA
The nurse is planning care for a patient who was diagnosed with deep vein thrombosis (DVT). What should be
included in this plan of care?
1. Activity as tolerated.
2. Measure and apply elastic antiembolism stockings.
3. Encourage the patient to sit out of bed several hours every day.
4. Assist patient with putting on tight-fitting pants.
Correct Answer: 2

Rationale 1: The plan of care for a patient with deep vein thrombosis (DVT) includes possible bed rest, the
duration of which is determined by the extent of leg edema.
Rationale 2: Elastic antiembolism stockings are frequently ordered to stimulate the muscle-pumping mechanism
that promotes the return of blood to the heart.
Rationale 3: The patient should be instructed to avoid prolonged standing, sitting, and to avoid leg crossing.
Rationale 4: The patient should be instructed to avoid tight-fitting garments.
Global Rationale: The plan of care for a patient with deep vein thrombosis (DVT) includes possible bed rest, the
duration of which is determined by the extent of leg edema. Elastic antiembolism stockings are frequently ordered
to stimulate the muscle-pumping mechanism that promotes the return of blood to the heart. Avoid prolonged
standing or sitting. Avoid tight-fitting garments.

Page Number: 999
Question 16
Type: MCSA
A patient who is being treated for a deep vein thrombosis (DVT) complains of chest pain and shortness of breath.
What should the nurse do first?
1. Elevate the head of the bed and begin oxygen therapy.
2. Measure the patient’s blood pressure.
3. Assess the extremity with the thrombosis.
4. Assess the pulses on the extremity with the thrombosis.
Correct Answer: 1

Rationale 1: Immediately report patient complaints of chest pain and shortness of breath, anxiety, or a sense of
impending doom. Prompt intervention to restore pulmonary blood flow can reduce the risk of significant adverse
effects. Initiate oxygen therapy and elevate the head of the bed.
Rationale 2: Measuring the patient’s blood pressure is not the priority and would delay the initiation of required
interventions in this situation.
Rationale 3: Assessing the extremity with the thrombosis is not the priority and would delay the initiation of
required interventions in this situation.
Rationale 4: Assessing the pulses on the extremity with the thrombosis is not the priority and would delay the
initiation of required interventions in this situation.
Global Rationale: Immediately report patient complaints of chest pain and shortness of breath, anxiety, or a
sense of impending doom. Prompt intervention to restore pulmonary blood flow can reduce the risk of significant
adverse effects. Initiate oxygen therapy and elevate the head of the bed. The other interventions are not the
priority and would delay the initiation of required interventions in this situation.

Page Number: 1003
Question 17
Type: MCSA
A 75-year-old patient is diagnosed with chronic venous insufficiency. What should the nurse instruct this patient?
1. Keep legs in a dependent position as much as possible.
2. Avoid the use of knee-high hose or girdles.
3. Limit ambulation.
4. Dangle legs over the side of the bed several times per day.

Correct Answer: 2
Rationale 1: Patients should be instructed to elevate the legs while resting and during sleep.
Rationale 2: Patients should be instructed not to wear anything that pinches legs, such as knee-high hose, garters,
or girdles and to wear elastic hose as prescribed.
Rationale 3: Patients should be instructed to walk as much as possible.
Rationale 4: Patients should be instructed to avoid sitting or standing for long periods of time; when sitting, do
not cross legs or allow pressure on the back of the knees, such as sitting on the side of the bed.
Global Rationale: Nursing care for the patient with chronic venous insufficiency includes elevating the legs
while resting and during sleep; walking as much as possible, but avoiding sitting or standing for long periods of
time; when sitting, do not cross legs or allow pressure on the back of the knees, such as sitting on the side of the
bed; do not wear anything that pinches legs, such as knee-high hose, garters, or girdles; and wearing elastic hose
as prescribed.

their care
complications.
Page Number: 1005
Question 18
Type: MCSA
An older patient is prescribed elastic graduated compression stockings. What should the nurse instruct the patient
about these stockings?
1. Wear the stockings continuously, except when showering.
2. Expect areas of skin breakdown under the stockings.
3. Wear the stockings primarily while sleeping.

4. Remove the stockings once per day and while sleeping.
Correct Answer: 4
Rationale 1: The stocking should be removed once per day.
Rationale 2: Skin breakdown is not anticipated with wearing the stockings and would need to be reported to the
physician.
Rationale 3: The stockings do not need to be removed for sleep.
Rationale 4: Elastic compression stockings compress the veins, promoting venous return from the lower
extremities. Because elastic stockings inhibit blood flow through small superficial vessels, they should be
removed at least once each day for at least 30 minutes.
Global Rationale: Elastic compression stockings compress the veins, promoting venous return from the lower
extremities. Because elastic stockings inhibit blood flow through small superficial vessels, they should be
removed at least once each day for at least 30 minutes. Skin breakdown is not anticipated with wearing the
stockings and would need to be reported to the physician. They do not need to be removed to sleep.

their care
Page Number: 1008
Question 19
Type: MCSA
The nurse calls a patient at home with the laboratory results from his visit of earlier in the day. Based on a review
of these results, what does the nurse expect the healthcare provider to advise?

1. Maintain the same daily dose of heparin.
2. Maintain the same daily dose of warfarin (Coumadin).
3. Increase the dose of warfarin (Coumadin) according to the previous instructions by the physician.
4. Stop taking the warfarin (Coumadin) until the next clinic appointment.
Correct Answer: 2
Rationale 1: Heparin is monitored by the aPPT test.
Rationale 2: Warfarin doses are adjusted to maintain the INR at 2.0‒3.0; therefore, this patient should be told to
maintain the same daily dose of medication.
Rationale 3: Warfarin doses are adjusted to maintain the INR at 2.0‒3.0; the patient’s dose does not need to be
increased.
Rationale 4: Warfarin doses are adjusted to maintain the INR at 2.0‒3.0; the patient should not stop the
medication.
Global Rationale: Prothrombin and INR tests are used to monitor the therapeutic effect of warfarin. Warfarin
doses are adjusted to maintain the INR at 2.0‒3.0; therefore, this patient should be told to maintain the same daily
dose of medication. Heparin is monitored by the aPPT test.

Page Number: 999

Question 20
Type: MCSA
A co-worker asks the nurse is to review the following discharge instructions with an assigned patient. Based on
the content to be reviewed, the nurse should realize that the patient has what health problem?
1. thromboangiitis obliterans
2. atherosclerosis
3. Raynaud disease
4. Buerger disease
Correct Answer: 3
Rationale 1: Thromboangiitis obliterans is an inflammatory process manifested by pain and diminished cessation
in the extremities. Digits or extremities may be pale, cyanotic or ruddy, and cool or cold to the touch. There are no
specific medications to treat this disorder.
Rationale 2: Atherosclerosis involves deposits of fat, which result in obstruction and hardening of the arteries.
Pain is the primary symptom. Management includes smoking cessation, lowering cholesterol, managing
hypertension, controlling diabetes and weight loss.
Rationale 3: The patient with Raynaud disease has spasms of the small arteries in the digits. There is no specific
treatment and the patient is taught to manage the disorder. This includes taking calcium channel blockers such as
nifedipine, avoiding exposure to cold and stress, smoking cessation, preventing injuries to the extremities and
managing stress.
Rationale 4: Thromboangiitis obliterans is an inflammatory process manifested by pain and diminished cessation
in the extremities. Digits or extremities may be pale, cyanotic or ruddy, and cool or cold to the touch. There are no
specific medications to treat this disorder. Smoking cessation is the one most important component in managing
this disorder. Blood flow may be improved by exercise, keeping the extremities warm and elevated, and avoiding
stress. Buerger disease is another name for this disorder.
Global Rationale: The patient with Raynaud disease has spasms of the small arteries in the digits. There is no
specific treatment and the patient is taught to manage the disorder. This includes taking calcium channel blockers
such as nifedipine, avoiding exposure to cold and stress, smoking cessation, preventing injuries to the extremities
and managing stress. Thromboangiitis obliterans is an inflammatory process manifested by pain and diminished
cessation in the extremities. Digits or extremities may be pale, cyanotic or ruddy, and cool or cold to the touch.
There are no specific medications to treat this disorder. Smoking cessation is the one most important component
in managing this disorder. Blood flow may be improved by exercise, keeping the extremities warm and elevated,
and avoiding stress. Buerger disease is another name for this disorder. Atherosclerosis involves deposits of fat,
which result in obstruction and hardening of the arteries. Pain is the primary symptom. Management includes
smoking cessation, lowering cholesterol, managing hypertension, controlling diabetes, and weight loss.

their care
Nursing/Integrated Concepts: Nursing Process: Evaluation
Page Number: 994
Question 21
Type: MCHS
A patient experiencing intermittent claudication points to the area of the body where this occurs. Place an “X” on
the diagram below indicating which body part is involved.

Correct Answer:
Rationale: Intermittent claudication is cramping or pain in the leg muscles brought on by exercise and relieved by
stress. It is a symptom of decreased blood flow to the lower extremity.
Global Rationale:

occlusive diseases.
Page Number: 984
Question 22
Type: MCSA
The nurse is teaching a community education class on hypertension and risk factors for this disorder. What is the
primary risk factor leading to the higher incidence of hypertension in older adults?
1. being a black adult
2. being a white male
3. having a family history of hypertension
4. age-related increase in the systolic blood pressure
Correct Answer: 4
Rationale 1: Being a black adult is a risk factor for hypertension but in not the primary risk factor.
Rationale 2: Being a white male is a risk factor for hypertension but in not the primary risk factor.
Rationale 3: Having a family history is a risk factor for hypertension but not the primary risk factor.
Rationale 4: An age-related increase in the systolic blood pressure is the primary factor leading to the high
incidence of hypertension in older adults. Systolic blood pressure continues to rise with aging, unlike the diastolic
blood pressure, which tends to rise until age 50 and then levels off.
Global Rationale: An age-related increase in the systolic blood pressure is the primary factor leading to the high
incidence of hypertension in older adults. Systolic blood pressure continues to rise with aging, unlike the diastolic
blood pressure, which tends to rise until age 50 and then levels off. The other options are also risk factors for
hypertension in older adults.

Client Need Sub:
their care

complications.
Page Number: 969

Question 23
Type: MCSA
A patient is diagnosed with a disorder in which deoxygenated blood is having difficulty returning to the heart and
lungs for reoxygenation. In which part of the peripheral vascular system is the origin of this patient’s disorder?
1. arteries
2. arterioles
3. capillaries
4. venules
Correct Answer: 4
Rationale 1: Arteries and arterioles are vessels within the arterial network, not the venous network.
Rationale 2: Arteries and arterioles are vessels within the arterial network, not the venous network.
Rationale 3: In the capillary beds, oxygen and nutrients are exchanged for metabolic wastes, and deoxygenated
blood begins its journey back to the heart. The problem with blood returning to the heart is not based in the
capillaries.
Rationale 4: In the capillary beds, oxygen and nutrients are exchanged for metabolic wastes, and deoxygenated
blood begins its journey back to the heart through venules, the smallest vessels of the venous network. The venous
network is where the problem with blood returning to the heart resides.
Global Rationale: In the capillary beds, oxygen and nutrients are exchanged for metabolic wastes, and
deoxygenated blood begins its journey back to the heart through venules, the smallest vessels of the venous
network. The venous network is where the problem with blood returning to the heart resides. Arteries and
arterioles are vessels within the arterial network, not the venous network.

occlusive diseases.
Page Number: 996-997
Question 24
Type: MCSA
A patient with some blood loss is maintaining a blood pressure of 100/60 mmHg. The nurse interprets this to
mean that the patient’s blood pressure is being maintained through the help of which structure?
1. arterioles
2. venules
3. capillaries
4. veins
Correct Answer: 1
Rationale 1: The smaller arterioles are less elastic than arteries but contain more smooth muscle, which promotes
their constriction (narrowing) and dilation (widening). In fact, arterioles exert the major control over arterial blood
pressure. With blood loss, the arterioles would constrict as a compensation mechanism to increase blood pressure.
Rationale 2: This would not happen at the capillary level and is possible in the arterial system, not the venous
system.
system.
system.

Global Rationale: The smaller arterioles are less elastic than arteries but contain more smooth muscle, which
promotes their constriction (narrowing) and dilation (widening). In fact, arterioles exert the major control over
arterial blood pressure. With blood loss, the arterioles would constrict as a compensation mechanism to increase
blood pressure. This would not happen at the capillary level and is possible in the arterial system, not the venous
system.

occlusive diseases.
Page Number: 967
Question 25
Type: MCSA
A patient is demonstrating a sign of blood pressure stabilization accompanied by a decreased urine output. What
should the nurse explain is the body’s mechanism responsible for this blood pressure stabilization?
1. response to chemoreceptors in the aortic arch
2. renal conservation of sodium and water
3. change in body temperature
4. intake of dietary fat and protein
Correct Answer: 2
Rationale 1: The changes are not reflective of intervention influenced by the chemoreceptors in the aortic arch,
body temperature changes, or dietary intake.
Rationale 2: Blood pressure is influenced by many factors. The kidneys help maintain blood pressure by
excreting or conserving sodium and water. When blood pressure decreases, the kidneys initiate the renin–
angiotensin mechanism. This stimulates vasoconstriction, which results in the release of the hormone aldosterone
from the adrenal cortex, and increases sodium ion reabsorption and water retention. In addition, pituitary release
of antidiuretic hormone (ADH) promotes renal reabsorption of water. The net result is an increase in blood
volume and a consequent increase in cardiac output and blood pressure. With the changes described, the kidneys
are compensating and causing the changes.
Global Rationale: Blood pressure is influenced by many factors. The kidneys help maintain blood pressure by
excreting or conserving sodium and water. When blood pressure decreases, the kidneys initiate the renin–
angiotensin mechanism. This stimulates vasoconstriction, which results in the release of the hormone aldosterone
from the adrenal cortex, and increases sodium ion reabsorption and water retention. In addition, pituitary release
of antidiuretic hormone (ADH) promotes renal reabsorption of water. The net result is an increase in blood
volume and a consequent increase in cardiac output and blood pressure. With the changes described, the kidneys
are compensating and causing the changes. The changes are not reflective of intervention influenced by the
chemoreceptors in the aortic arch, body temperature changes, or dietary intake.

their care
Page Number: 969
Question 26:
Type: MCMA
The nurse suspects that a patient’s hypertension is being influenced by sympathetic nervous system stimulation.
Which substances should the nurse identify as contributing to this patient’s elevated blood pressure?

1. epinephrine
2. angiotensin II
3. norepinephrine
4. adrenomedullin
5. antidiuretic hormone
Correct Answer: 1, 2, 3, 5
Rationale 1: Epinephrine is a vasoconstrictor and will increase blood pressure.
Rationale 2: Angiotensin II is a hormone that increases blood pressure.
Rationale 3: Norepinephrine is a vasoconstrictor that increases blood pressure.
Rationale 4: Adrenomedullin is a hormone that decreases blood pressure.
Rationale 5: Antidiuretic hormone is a vasoconstrictor that increases blood pressure.
Global Rationale: Epinephrine and norepinephrine, and the hormones angiotensin II and antidiuretic hormone
are vasoconstrictors that increase the blood pressure. Adrenomedullin is a hormone that decreases blood pressure.

Page Number: 968
Question 27
Type: MCMA

A patient makes an appointment to see the primary healthcare provider because during a routine eye examination
the ophthalmologist asked how long the patient had been treated for hypertension. What did the ophthalmologist
observe that caused the health problem of hypertension to be discussed?
1. nystagmus
2. papilledema
3. astigmatism
4. retinal exudates
5. retinal hemorrhages
Rationale 1: Nystagmus is not caused by changes in the eye resulting from hypertension.
Rationale 2: Manifestations of hypertension result from target organ damage, including the eyes. Eye changes
include papilledema or swelling of the optic nerve.
Rationale 3: Astigmatism is not caused by changes in the eye resulting from hypertension.
include retinal exudates.
include retinal hemorrhages.
Global Rationale: Manifestations of hypertension result from target organ damage, including the eyes. Eye
changes include visual disturbances, narrowed arterioles in the retina along with hemorrhages, exudates, and
papilledema or swelling of the optic nerve. Nystagmus and astigmatism are not caused by changes in the eye
resulting from hypertension.


Page Number: 969
Question 28
Type: MCMA
A patient with hypertension is prescribed the alpha-adrenergic blocker doxazosin (Cardura). What should the
nurse instruct the patient about this medication?
1. Take the medication at bedtime.

2. Change positions slowly and sit down if dizziness occurs.
3. Notify the primary healthcare provider if nasal congestion develops.
4. Restrict the intake of all alcoholic beverages and items containing caffeine.
5. Avoid engaging in hazardous activity for 12 to 24 hours after the first dose.
Rationale 1: Because of the risk of fainting after taking the first dose of this medication, the medication should be
taken at bedtime.
Rationale 2: This drug can cause dizziness. The patient should change positions slowly and sit down if dizziness
occurs.
Rationale 3: The primary healthcare provider should be notified if nasal congestion occurs.
Rationale 4: There is no need to restrict the intake of alcoholic beverages and items containing caffeine while
taking this medication.
Rationale 5: Because of the risk of fainting, the patient should not drive or engage in hazardous activity for 12 to
24 hours after taking the first dose.
Global Rationale: Because of the risk of fainting after taking the first dose of this medication the medication
should be taken at bedtime. This drug can cause dizziness. The patient should change positions slowly and sit
down if dizziness occurs. The primary healthcare provider should be notified if nasal congestion occurs. Because
of the risk of fainting, the patient should not drive or engage in hazardous activity for 12 to 24 hours after taking
the first dose. There is no need to restrict the intake of alcoholic beverages and items containing caffeine while
taking this medication.
their care
Page Number: 974
Question 29
Type: FIB
A patient with hypertension weighing 115 kg is advised by the primary healthcare provider to lose 10% of total
body weight over the next 6 months. How many lbs. of weight loss per month should the nurse instruct the patient
to establish as a goal?
Standard Text: Record your answer rounding to the nearest whole number.
Answer: 4 lbs.
Global Rationale: The patient weighs 115 kg. To convert this weight into lbs. multiply the weight in kg by 2.2
lbs. or 115 × 2.2 = 253 lbs. The patient is counseled to lose 10% of total body weight or 253 lbs. × 10% = 25.3
lbs. If this weight is to be lost over 6 months, divide the total weight to lose by 6 or 25.3/6 = 4.216 lbs. When
rounding to the nearest whole number, the patient should set a goal to lose 4 lbs. per month.

Client Need Sub:
AACN Essentials Competencies: IX 7. Provide appropriate patient teaching that reflects developmental stage,
their care
complications.
Page Number: 977
Question 30
Type: MCMA
A patient is suspected as having secondary hypertension. For which diagnostic tests should the nurse prepare this
patient?
1. bladder scan
2. renal lithotripsy
3. renal ultrasound
4. renal arteriogram
5. intravenous pyelogram
Rationale 1: A bladder scan determines the amount of residual urine in the bladder.
Rationale 2: Renal lithotripsy is done when renal calculi are diagnosed.
Rationale 3: In secondary hypertension, a renal cause needs to be ruled out. A renal ultrasound might be
prescribed for this patient.
Rationale 4: In secondary hypertension, a renal cause needs to be ruled out. A renal arteriogram might be
Rationale 5: In secondary hypertension, a renal cause needs to be ruled out. An intravenous pyelogram might be
Global Rationale: In secondary hypertension, a renal cause needs to be ruled out. A renal ultrasound,
arteriogram, or intravenous pyelogram might be prescribed. A bladder scan determines the amount of residual
urine in the bladder. Renal lithotripsy is done when renal calculi are diagnosed.

their care
Learning Outcome: 5. Relate the manifestations and diagnostic test results to the etiology and pathophysiology
of common peripheral vascular and lymphatic disorders.
MNL Learning Outcome: 6.1.2. Differentiate the manifestations and diagnostic tests for disorders of blood
Page Number: 980
Question 31
Type: MCMA
While conducting an assessment, the nurse suspects that a patient is experiencing a hypertensive crisis. What did
the nurse assess to make this clinical decision?
1. acute onset of confusion

2. onset of projectile vomiting
3. complaints of a severe headache
4. systolic blood pressure 198 mmHg
5. diastolic blood pressure 148 mmHg
Rationale 1: Manifestations of hypertensive crisis include confusion.
Rationale 2: Projectile vomiting is not a manifestation of hypertensive crisis.
Rationale 3: Manifestations of hypertensive crisis include headache.
Rationale 4: Manifestations of hypertensive crisis include systolic blood pressure greater than 180 mmHg.
Rationale 5: Manifestations of hypertensive crisis include diastolic blood pressure greater than 120 mmHg.
Global Rationale: Manifestations of hypertensive crisis include confusion, headache, diastolic blood pressure
greater than 120 mmHg, and systolic blood pressure greater than 180 mmHg. Projectile vomiting is not a
manifestation of hypertensive crisis.

MNL Learning Outcome: 6.1.2. Differentiate the manifestations and diagnostic tests for disorders of blood
Page Number: 981
Question 32
Type: MCMA
A patient comes into the clinic complaining of a new onset of hoarseness. What additional assessment findings
should the nurse use to suspect that this patient is experiencing a thoracic aneurysm?
1. brassy cough
2. lumbar back pain
3. edema of the face
4. distended neck veins
5. absent pulses in the wrists
Rationale 1: Manifestations of a thoracic aneurysm include a brassy cough if pressing on the trachea.
Rationale 2: Lumbar pain is associated with an abdominal aneurysm.
Rationale 3: Manifestations of a thoracic aneurysm include edema of the face.
Rationale 4: Manifestations of a thoracic aneurysm include distended neck veins.

Rationale 5: Absent pulses in the wrists are associated with an aortic aneurysm.
Global Rationale: Manifestations of a thoracic aneurysm include a brassy cough, facial edema, and distended
neck veins. Lumbar pain is associated with an abdominal aneurysm. Absent pulses in the wrists are associated
with an aortic aneurysm.

MNL Learning Outcome: 6.6.2. Differentiate the manifestations and complications of an aneurysm.
Page Number: 983
Question 33
Type: MCMA
A patient is diagnosed with an aortic dissection. Which medications should the nurse expect to be prescribed for
this patient?
1. verapamil (Isoptin)
2. esmolol (Brevibloc)
3. diltiazem (Cardizem)
4. hydralazine (Apresoline)
5. sodium nitroprusside (Nipride)
Rationale 1: Calcium channel blockers such as verapamil (Isoptin) may be used to treat aortic dissection.
Rationale 2: Patients with aortic dissection are initially treated with intravenous beta-blockers such as esmolol
(Brevibloc) to reduce the heart rate to about 60 bpm.

Rationale 3: Calcium channel blockers such as diltiazem (Cardizem) may be used to treat aortic dissection.
Rationale 4: Direct vasodilators such as hydralazine (Apresoline) are avoided because they may actually worsen
the dissection.
Rationale 5: Sodium nitroprusside (Nipride) infusion may be started to reduce the systolic pressure to 120 mmHg
or less.
Global Rationale: Patients with aortic dissection are initially treated with intravenous beta-blockers such as
esmolol (Brevibloc) to reduce the heart rate to about 60 bpm. Sodium nitroprusside (Nipride) infusion is started
concurrently to reduce the systolic pressure to 120 mmHg or less. Calcium channel blockers such as verapamil
(Isoptin) or diltiazem (Cardizem) also may be used. Direct vasodilators such as hydralazine (Apresoline) are
avoided because they may actually worsen the dissection.

Page Number: 984
Question 34
Type: MCMA
The nurse is concerned that a patient recovering from surgery to repair an abdominal aneurysm is developing
bowel ischemia. What assessment findings did the nurse use to come to this conclusion?
1. diarrhea
2. obvious bloody stool
3. abdominal distention
4. onset of abdominal pain
5. hyperactive bowel sounds

Rationale 1: Manifestations of bowel ischemia include diarrhea.
Rationale 2: Manifestations of bowel ischemia include occult or fresh blood in stools.
Rationale 3: Manifestations of bowel ischemia include abdominal distention.
Rationale 4: Manifestations of bowel ischemia include abdominal pain.
Rationale 5: A change in bowel sounds is not a manifestation of bowel ischemia.
Global Rationale: Manifestations of bowel ischemia include diarrhea, occult or fresh blood in stools, abdominal
distention, and abdominal pain. A change in bowel sounds is not a manifestation of bowel ischemia.

Page Number: 985
Question 35
Type: MCMA
The home care nurse instructs a patient with peripheral atherosclerosis on foot care. Which observations indicate
that teaching has been effective?
1. The patient uses a razor to cut the toenails.

2. The patient walks barefoot in the bedroom.
3. The patient washes feet and legs with warm water.
4. The patient applies powder to the feet after a shower.
5. The patient inspects feet and legs each day with a mirror.
Rationale 1: A professional foot care provider should trim toenails.
Rationale 2: The patient should be instructed always to wear shoes and not to go barefoot.
Rationale 3: Foot care for the patient with peripheral atherosclerosis includes washing the feet and legs with
warm water.
Rationale 4: Foot care for the patient with peripheral atherosclerosis includes applying powder to the feet after a
shower.
Rationale 5: Foot care for the patient with peripheral atherosclerosis includes inspecting the feet and legs each
day with a mirror.
Global Rationale: Foot care for the patient with peripheral atherosclerosis includes washing the feet and legs
with warm water, applying powder to the feet after a shower, and inspecting the feet and legs each day with a
mirror. A professional foot care provider should trim toenails. The patient should be instructed always to wear
shoes and not to go barefoot.

AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of
psychobiological interventions
Nursing/Integrated Concepts: Nursing Process: Evaluation
Page Number: 989
Question 36
Type: MCMA
After inspecting a patient’s left lower leg, the nurse leaves the patient’s room and asks the charge nurse to notify
the patient’s healthcare provider regarding a possible arterial thrombosis. What did the nurse assess to make this
decision?

1. absent pedal pulses

2. skin cold to the touch
3. +4 edema on the ankle
4. foot unresponsive to sensation
5. line of demarcation across the foot
Rationale 1: Manifestations of arterial thrombosis include absent distal pulses.
Rationale 2: Manifestations of arterial thrombosis include tissue that is cool or cold.
Rationale 3: Edema is not a manifestation of arterial thrombosis.
Rationale 4: Manifestations of arterial thrombosis include paralysis of the affected extremity.
Rationale 5: Manifestations of arterial thrombosis include a line of demarcation between normal and ischemic
tissue.
Global Rationale: Manifestations of arterial thrombosis include absent distal pulses, tissue that is cool or cold to
the touch, paralysis of the affected extremity, and a line of demarcation between normal and ischemic tissue.
Edema is not a manifestation of arterial thrombosis.

occlusive diseases.
Page Number: 995
Question 37
Type: MCMA
A patient with a history of recurrent venous micro emboli is scheduled for an insertion of a Greenfield filter. What
should the nurse explain to the patient about this procedure?
1. The filter can be inserted under fluoroscopy.

2. Mortality from the insertion of the filter is low.
3. The filter will need to be replaced every 6 months.
4. The patient may only need local anesthesia for the procedure.
5. The filter traps emboli while maintaining the patency of the vena cava.
Rationale 1: The filter can be inserted under fluoroscopy.
Rationale 2: Mortality associated with the filter is very low.
Rationale 3: There is no information to support the frequency in which the filter needs to be replaced.
Rationale 4: The filter can be inserted with local anesthesia.
Rationale 5: The Greenfield filter is widely used for its ability to trap emboli within its apex while maintaining
patency of the vena cava.
Global Rationale: The Greenfield filter is widely used for its ability to trap emboli within its apex while
maintaining patency of the vena cava. The filter can be inserted under fluoroscopy with local anesthesia. Mortality
associated with the filter is very low. There is no information to support the frequency in which the filter needs to
be replaced.

their care
Page Number: 999
Question 38
Type: MCMA
A patient with a history of deep venous thrombosis is prescribed dabigatran (Pradaxa). What should the nurse
instruct the patient about this medication?
1. Use a straight razor to shave if necessary.

2. Limited amounts of alcohol are permitted.
3. A reversal agent for this medication is not available.
4. The cost of this medication is higher than for warfarin.
5. Laboratory test monitoring is not necessary for this medication.
Rationale 1: The patient should be instructed to prevent injury and bleeding. A straight razor would be
contraindicated.
Rationale 2: Alcohol should be avoided while taking this medication.
Rationale 3: Rivaroxaban (Xarelto) acts as a selective factor X inhibitor, inactivating the cascade of coagulation.
There is no reversal agent available for this drug.
The cost is significantly higher for this drug when compared to warfarin.
This drug does not require monitoring like warfarin does.
Global Rationale: Rivaroxaban (Xarelto) acts as a selective factor X inhibitor, inactivating the cascade of
coagulation. It does not require monitoring like warfarin does, however, there is no reversal agent available for
this drug. The cost is significantly higher for this drug when compared to warfarin. The patient should be
instructed to prevent injury and bleeding. A straight razor would be contraindicated. Alcohol should be avoided
while taking this medication.

AACN Essentials Competencies: IX 7. Provide appropriate patient teaching that reflects developmental stage,
their care
Page Number: 1000-1001
Question 39
Type: MCMA
The nurse completes an assessment with a patient and begins planning care for a venous leg ulcer. What
manifestations did the nurse use to make this clinical decision?
1. There is an ulcer located on the toe.

2. The ulcer is superficial and pink.
3. Pulses in the foot are decreased.
4. Skin over the leg is discolored brown.
5. The patient rates pain as 8 on a scale from 0 to 10.
Rationale 1: An ulcer on the toe is associated with an arterial ulcer.
Rationale 2: Manifestations of a venous ulcer include a superficial wound that is pink.
Rationale 3: Decreased pulses in the foot are associated with an arterial ulcer.
Rationale 4: Manifestations of a venous ulcer include brown skin discoloration over the lower extremity.
Rationale 5: Severe pain is associated with an arterial ulcer.
Global Rationale: Manifestations of a venous ulcer include superficial wound that is pink and brown skin
discoloration. Arterial ulcers are located on the toe. Pulses are decreased with an arterial ulcer. Severe pain is
associated with an arterial ulcer.

occlusive diseases.
Page Number: 1004
Question 40
Type: MCMA
A patient is recovering from surgery for varicose veins. What information should the nurse include in this
patient’s postoperative teaching?
1. Elevate the extremities.

2. Increase ambulation gradually.
3. Sit for no more than 1 hour at a time.
4. Avoid standing for more than 15 minutes.
5. Keep pressure dressing applied for 6 weeks.
Rationale 1: Postoperative care for varicose veins includes elevating the extremities to minimize postoperative
edema.
Rationale 2: Postoperative care for varicose veins includes gradually increasing amounts of ambulation.
Rationale 3: Sitting is prohibited during the initial recovery period, and is gradually reintroduced as deemed
appropriate by the surgeon.
Rationale 4: Standing is prohibited during the initial recovery period, and is gradually reintroduced as deemed
appropriate by the surgeon.
Rationale 5: Postoperative care for varicose veins includes applying pressure bandages for a minimum of 6
weeks.
Global Rationale: Postoperative care for varicose veins includes applying pressure bandages for a minimum of 6
weeks, elevating the extremities to minimize postoperative edema, and gradually increasing amounts of
ambulation. Sitting and standing are prohibited during the initial recovery period, and are gradually reintroduced
as deemed appropriate by the surgeon.

their care
Page Number: 1007


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LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test

1. Provide stress-reduction techniques.

2. Inform the physician so antihypertensive medication can be prescribed.

3. Offer the patient a glass of water.

4. Remeasure the blood pressure in a few minutes.

Rationale 1: The patient may not feel stressed.

Rationale 2: The patient may not need antihypertensive medication.

Cognitive Level: Applying

Rationale 2: This is incorrect.

Standard Text: Select all that apply.

1. Review the DASH diet.

2. Begin a walking program, and progress to 30 minutes 5 to 6 days each week.

3. Plan a weight lifting regimen.

4. Eliminate dairy products from the diet.

5. Restrict fluid intake.

LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank

Rationale 5: Fluid restriction is not indicated.

Cognitive Level: Applying

1. Ask if the patient is taking the prescribed medication.

2. Suggest to the physician that another medication be added.

LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank

Rationale 2: Further assessment is indicated prior to this intervention.

Rationale 3: Further assessment is indicated prior to this intervention.

Cognitive Level: Applying

LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank

2. Ask the patient to cough.

3. Get the physician.

4. Auscultate the mass.

Rationale 3: Further assessment is needed before contacting the physician.

Cognitive Level: Applying

LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank

Standard Text: Select all that apply.

1. urine output 45 mL/hr

2. complaint of groin pain

3. abdominal dressing dry and intact

4. respiratory rate 16 and regular

5. complaint of back discomfort

Rationale 3: A dry and intact abdominal dressing is a normal finding.

Rationale 4: A respiratory rate of 16 and regular is a normal finding.

Cognitive Level: Analyzing

LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank

1. rubor with extremity elevation

2. normal hair distribution bilaterally over lower extremities

3. peripheral pulses present bilaterally

4. complaints of leg pain upon rest

Rationale 2: Manifestations of peripheral atherosclerosis include thin, shiny, hairless skin.

Rationale 3: Manifestations of peripheral atherosclerosis include diminished or absent peripheral pulses.

Rationale 4: Manifestations of peripheral atherosclerosis include intermittent claudication; pain at rest;

Cognitive Level: Analyzing

LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank

1. thigh pressure higher than the arm

2. calf pressure higher than the arm

3. calf pressure lower than the arm

4. no difference between the arm or leg

Cognitive Level: Analyzing

LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank

1. Encourage patient to reduce level of exercise.

2. Discuss smoking cessation techniques.

3. Keep extremities cool.

4. Assist with pillow placement under knees.

LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank

1. Medications are the only cure.

2. Surgical procedures can be performed to cure this disorder.