NCLEX-PN
Peripheral Vascular Disease NCLEX Questions
Extract:
Question 1 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 2 of 5
The client with a left-sided mastectomy is diagnosed with elephantiasis of the left arm. Which signs/symptoms should the nurse expect to assess?
Correct Answer: A
Rationale: Elephantiasis causes chronic lymphedema, leading to arm edema from axilla to fingertips (
A). Pain/redness (
B) suggests infection, tented turgor (
C) is dehydration, and nipple changes (
D) are breast cancer signs.
Question 3 of 5
The nurse is assessing a client with pericarditis. Which finding is most characteristic?
Correct Answer: A
Rationale: Pericarditis causes chest pain that is typically relieved by leaning forward, reducing pressure on the inflamed pericardium.
Question 4 of 5
The client is being admitted with Coumadin (warfarin, an anticoagulant) toxicity. Which laboratory data should the nurse monitor?
Correct Answer: C
Rationale: Warfarin toxicity is monitored via INR (
C), which reflects bleeding risk. BUN (
A) assesses kidneys, bilirubin (
B) liver, and PTT (
D) is for heparin.
Question 5 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.