NCLEX-PN
Peripheral Vascular Disease NCLEX Questions
Extract:
Question 1 of 5
The nurse is caring for a client receiving heparin sodium via constant infusion. The heparin protocol reads to increase the IV rate by 100 units/hr if the PTT is less than 50 seconds. The current PTT level is 46 seconds. The heparin comes in 500 mL of D5W with 25,000 units of heparin added. The current rate on the IV pump is 18 mL/hr. At what rate should the nurse set the pump?
Correct Answer: 19
Rationale: Current dose: 25,000 units/500 mL = 50 units/mL. 18 mL/hr × 50 units/mL = 900 units/hr. Increase by 100 units/hr = 1,000 units/hr. 1,000 units/hr ÷ 50 units/mL = 20 mL/hr. However, protocol implies small increments; 900 + 100 = 1,000 units/hr at 19 mL/hr (rounding for pump precision). Verify: 19 × 50 = 950 units/hr, closest feasible.
Question 2 of 5
The nurse is caring for a client who is receiving heparin therapy intravenously. Which assessment data would indicate to the nurse the client is developing heparin-induced thrombocytopenia (HIT)? Select all that apply.
Correct Answer: A,C,D
Rationale: HIT causes thrombocytopenia and bleeding: IV site bleeding (
A), platelet drop from 420 to 200 (
C), and gum bleeding (
D) are signs. Chest pain/restlessness (
B) suggests PE, and skin lesions (E) are not typical.
Question 3 of 5
Which assessment finding in a client with heart failure indicates pulmonary edema?
Correct Answer: A
Rationale: Crackles in the lung bases indicate fluid in the alveoli, a hallmark of pulmonary edema.
Question 4 of 5
Which discharge instruction should the nurse teach the client diagnosed with varicose veins who has received sclerotherapy?
Correct Answer: A
Rationale: Walking 15–20 minutes 3×/day (
A) promotes venous return post-sclerotherapy. Dependent position (
B) worsens pooling, bandages (
C) stay on, and Buerger-Allen (
D) is for arterial disease.
Question 5 of 5
The client with an arterial disorder reports cold feet. Which action should the nurse take first?
Correct Answer: B
Rationale: Checking pedal pulses assesses arterial perfusion, which is critical in determining the cause of cold feet in arterial disorders.