ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 30 : Assessment and Management of Patients With Vascular Disorders and Problems of Peripheral Circulation Questions
Question 1 of 5
A nurse is closely monitoring a patient who has recently been diagnosed with an abdominal aortic aneurysm. What assessment finding would signal an impending rupture of the patients aneurysm?
Correct Answer: C
Rationale: Signs of impending rupture include severe back or abdominal pain, which may be persistent or intermittent. Impending rupture is not typically signaled by increased blood pressure, bradycardia, cessation of pulsing, or hemoptysis.
Question 2 of 5
The nurse is reviewing the physiological factors that affect a patients cardiovascular health and tissue oxygenation. What is the systemic arteriovenous oxygen difference?
Correct Answer: D
Rationale: The average amount of oxygen removed collectively by all of the body tissues is about 25%. This means that the blood in the vena cava contains about 25% less oxygen than aortic blood. This is known as the systemic arteriovenous oxygen difference. The other answers do not apply.
Question 3 of 5
The nurse is evaluating a patients diagnosis of arterial insufficiency with reference to the adequacy of the patients blood flow. On what physiological variables does adequate blood flow depend?
Correct Answer: A,B,E
Rationale: Adequate blood flow depends on the efficiency of the heart as a pump, the patency and responsiveness of the blood vessels, and the adequacy of circulating blood volume. Adequacy of blood flow does not primarily depend on the size of red cells or their ratio to the number of platelets.
Question 4 of 5
A nurse is assessing a new patient who is diagnosed with PAD. The nurse cannot feel the pulse in the patients left foot. How should the nurse proceed with assessment?
Correct Answer: D
Rationale: When pulses cannot be reliably palpated, a hand-held continuous wave (CW) Doppler ultrasound device may be used to hear (insonate) the blood flow in vessels. CT is not normally warranted and the application of a tourniquet poses health risks and will not aid assessment. Elevating the extremity would make palpation more difficult.
Question 5 of 5
A medical nurse has admitted four patients over the course of a 12-hour shift. For which patient would assessment of ankle-brachial index (ABI) be most clearly warranted?
Correct Answer: C
Rationale: Nurses should perform a baseline ABI on any patient with decreased pulses or any patient 50 years of age or older with a history of diabetes or smoking. The other answers do not apply.