ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 36 : Care of Patients with Vascular Problems Questions
Question 1 of 5
A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.)
Correct Answer: B,D,E
Rationale: This client may have a rupturing aneurysm. The nurse should notify the Rapid Response Team and perform frequent assessments of pulses and vital signs. Pain medication could lower blood pressure further, and consent should be handled after the physician explains the procedure.
Question 2 of 5
A nurse is caring for a client who weighs 207 pounds and is started on enoxaparin (Lovenox). How much enoxaparin does the nurse anticipate administering? (Record your answer using a whole number.) __ mg
Correct Answer: A
Rationale: The dose of enoxaparin is 1 mg/kg body weight, not to exceed 90 mg. This client weighs 207 pounds (94 kg), so the nurse anticipates administering the maximum dose of 90 mg.
Question 3 of 5
A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would assess the locally primary interview?
Correct Answer: D
Rationale: The student should not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure should be taken and compared in both arms. Prolonged capillary refill is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits should be auscultated.
Question 4 of 5
The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning?
Correct Answer: D
Rationale: Triglycerides in men should be below 160 mg/dL. The other values are within acceptable ranges for adult males.
Question 5 of 5
The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet?
Correct Answer: B
Rationale: The diet recommended for this client would be low in saturated fats and red meat, high in vegetables and whole grains (fiber), low in salt, and low in trans fat. The best choice is baked chicken with broccoli and tomatoes. The French fries have too much fat and the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat and no vegetables.