HESI RN MED SURG

1. The nurse is assessing a 48-year-old client with a history of smoking during a

routine clinic visit. The client, who exercises regularly, reports having pain in the calf

during exercise that disappears at rest. Which of the following findings requires further evaluation?

1. Heart rate 57 bpm.

2. SpO2 of 94% on room air.

3. Blood pressure 134/82.

4. Ankle-brachial index of 0.65.

An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular disease in a client who is

experiencing intermittent claudication. Normal ABI 1-1.4. A Doppler ultrasound is indicated for further

evaluation. The bradycardic heart rate is acceptable in an athletic client with a normal blood pressure.

The SpO2 is acceptable; the client has a smoking history.

2. 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.

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

 1 / 4

3. An overweight client taking warfarin (Coumadin) has dry skin due to decreased

 2 / 4

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.

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

4. 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.”

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

 3 / 4

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

Powered by qwivy(www.qwivy.org)

 4 / 4