Peripheral Vascular Disease NCLEX

Extract:

Question 1 of 5

Which finding in a client with cardiomyopathy indicates a need for immediate action?

Correct Answer: B

Rationale: A new irregular heart rhythm may indicate a life-threatening arrhythmia, requiring immediate intervention.

Question 2 of 5

The unlicensed assistive personnel (UAP) is caring for the client diagnosed with chronic venous insufficiency. Which action would warrant immediate intervention from the nurse?

A. Removing compression stockings before assisting the client to bed. B. Taking the client’s blood pressure manually after using the machine. C. Assisting the client by opening the milk carton on the lunch tray. D. Calculating the client’s shift intake and output with a pen and paper.

Correct Answer: A

Rationale: Removing compression stockings (
A) at night is incorrect; they should be worn to reduce edema. Manual BP (
B), opening cartons (
C), and I/O Calculation(ans only)s (
D) are appropriate.

Question 3 of 5

Which complication should the nurse monitor for in a client with pericarditis?

A. Cardiac tamponade B. Pneumonia C. Renal failure D. Seizures

Correct Answer: A

Rationale: Cardiac tamponade is a serious complication of pericarditis, where fluid accumulation compresses the heart.

Question 4 of 5

When assessing the client's lower leg, which findings characteristic of venous stasis ulcers is the nurse most likely to find? Select all that apply.

A. Purulent drainage from lesions B. Blanched patches around open areas C. Dark brown, dry, and crusty skin D. Fluid-filled blisters E. Edema in the lower legs F. Fine red rash below the knee

Correct Answer: C,E

Rationale: Venous stasis ulcers are typically characterized by dark brown, dry, crusty skin due to hemosiderin deposition and edema in the lower legs due to venous insufficiency.

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?

Your Answer:

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.

Peripheral Vascular Disease NCLEX | Nurselytic

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