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Med-Surg II HESI Exam - Set Two, Questions & Answers

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Med-Surg II HESI Exam - Set Two, Questions & Answers-The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports h... aving pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation? 1. Heart rate 57 bpm. 2. SpO2 of 94% on room air. 3. Blood pressure 134/82. 4. Ankle-brachial index of 0.65. - 4 A client with peripheral vascular disease has undergone a right femoralpopliteal bypass graft. The blood pressure has decreased from 124/80 to 94/62. What should the nurse assess first? 1. IV fluid solution. 2. Pedal pulses. 3. Nasal cannula flow rate. 4. Capillary refill. - 2 An overweight client taking warfarin (Coumadin) has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply. 1. Apply lanolin or petroleum jelly to intact skin. 2. Follow a reduced-calorie, reduced-fat diet. 3. Inspect the involved areas daily for new ulcerations. 4. Instruct the client to limit activities of daily living (ADLs). 5. Use an electric razor to shave. - 1, 2, 3, 5 The nurse is caring for a client with peripheral artery disease who has recently been prescribed clopidogrel (Plavix). The nurse understands that more teaching is necessary when the client states which of the following: 1. "I should not be surprised if I bruise easier or if my gums bleed a little when brushing my teeth." 2. "It doesn't really matter if I take this medicine with or without food, whatever works best for my stomach." 3. "I should stop taking Plavix if it makes me feel weak and dizzy." 4. "The doctor prescribed this medicine to make my platelets less likely to stick together and help prevent clots from forming." - 3 A client is receiving Cilostazol (Pletal) for peripheral arterial disease causing intermittent claudication. The nurse determines this medication is effective when the client reports which of the following? 1. "I am having fewer aches and pains." 2. "I do not have headaches anymore." 3. "I am able to walk further without leg pain." 4. "My toes are turning grayish black in color." - 3 The client admitted with peripheral vascular disease (PVD) asks the nurse why her legs hurt when she walks. The nurse bases a response on the knowledge that the main characteristic of PVD is: 1. Decreased blood flow. 2. Increased blood flow. 3. Slow blood flow. 4. Thrombus formation. - 1 The nurse is planning care for a client who is diagnosed with peripheral vascular disease (PVD) and has a history of heart failure. The nurse should develop a plan of care that is based on the fact that the client may have a low tolerance for exercise related to: 1. Decreased blood flow. 2. Increased blood flow. 3. Decreased pain. 4. Increased blood viscosity. - 1 When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to: 1. Competent venous valves. 2. Decreased blood volume. 3. Increase in muscular activity. 4. Increased venous pressure. - 4 The nurse is obtaining the pulse of a client who has had a femoral-popliteal bypass surgery 6 hours ago. (See below) Which assessment provides the most accurate information about the client's postoperative status? - 4 The presence of a strong dorsalis pedis pulse indicates that there is circulation to the extremity distal to the surgery indicating that the graft between the femoral and popliteal artery is allowing blood to circulate effectively. Answer 1 shows the nurse obtaining the radial pulse; answer 2 shows the femoral pulse, which is proximal to the surgery site and will not indicate circulation distal to the surgery site. Answer 3 shows the nurse obtaining an apical pulse. CN: Reduction of risk potential; CL: Analyze The nurse is teaching a client about risk factors associated with atherosclerosis and how to reduce the risk. Which of the following is a risk factor that the client is not able to modify? 1. Diabetes. 2. Age. 3. Exercise level. 4. Dietary preferences. - 2 The nurse is assessing the lower extremities of the client with peripheral vascular disease (PVD). During the assessment, the nurse should expect to find which of the following clinical manifestations of PVD? Select all that apply. 1. Hairy legs. 2. Mottled skin. 3. Pink skin. 4. Coolness. 5. Moist skin. - 2 The nurse is unable to palpate the client's left pedal pulses. Which of the following actions should the nurse take next? 1. Auscultate the pulses with a stethoscope. 2. Call the physician. 3. Use a Doppler ultrasound device. 4. Inspect the lower left extremity. - 3 [Show More]

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