HKR

MSC: Integrated Process: Nursing Process: Assessment
NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation
11. An older patient with peripheral vascular disease (PVD) is explaining the daily foot
care regimen to the family practice clinic NP. What statement by the patient may
indicate a barrier to proper foot care?
a. I nearly always wear comfy sweatpants&house shoes.
b. Im glad I get energy assistance so my house isnt so cold.
c. My daughter makes sure I have plenty of lotion for my feet.
d. My hands shake when I try to do things requiring coordination.
ANSWER: D
Victim with PVD need to pay special attention to their feet. Toenails need to be kept
short&cut straight across. The patient whose hands shake may cause injury when
trimming toenails. The NP should refer this patient to a podiatrist. Comfy
sweatpants&house shoes are generally loose&not restrictive, which is important for
victim with PVD. Keeping the house at a comfortable temperature makes it less likely the
patient will use alternative heat sources, such as heating pads, to stay warm. The patient
should keep the feet moist&soft with lotion.
DIF: Analyzing/Analysis REF: 739

KEY: Peripheral vascular disease| self-care|
home safety MSC: Integrated Process: Nursing
Process: Analysis
NOT: Patient Needs Category: Health Promotion&Maintenance
12. A patient is taking warfarin (Coumadin)&asks the NP if taking St. Johns wort is
acceptable. What response by the NP is best?
a. No, it may interfere with the warfarin.
b. There isnt any information about that.
c. Why would you want to take that?
d. Yes, it is a good supplement for you.
ANSWER: A
Many foods&drugs interfere with warfarin, St. Johns wort being one of them. The NP
should advise the patient against taking it. The other answers are not accurate.
DIF: Understanding/Comprehension REF: 747

KEY: Anticoagulants| herbs&supplements| medication-food interactions| patient education
MSC: Integrated Process: Teaching/Learning
NOT: Patient Needs Category: Physiological Integrity: Pharmacological&Parenteral
Therapies
13. A NP is teaching a larger female patient about alcohol intake&how it affects

hypertension. The patient asks if drinking two beers a night is an acceptable intake.
What answer by the NP is best?
a. No, women should only have one beer a day as a general rule.
b. No, you should not drink any alcohol with hypertension.
c. Yes, since you are larger, you can have more alcohol.
d. Yes, two beers per day is an acceptable amount of alcohol.
ANSWER: A
Alcohol intake should be limited to two drinks a day for men&one drink a day for women.
A drink is classified as one beer, 1.5 ounces of hard liquor, or 5 ounces of wine. Limited
alcohol intake is acceptable with hypertension. The womans size does not matter.
DIF: Understanding/Comprehension REF: 726

KEY: Hypertension| lifestyle choices| patient
education MSC: Integrated Process:
Teaching/Learning
NOT: Patient Needs Category: Health Promotion&Maintenance
14. A NP is caring for four victim. Which one should the NP see first?
a. Patient who needs a beta blocker,&has a blood pressure of 92/58 mm Hg
b. Patient who had a first dose of captopril (Capoten)&needs to use the bathroom
c. Hypertensive patient with a blood pressure of 188/92 mm Hg
d. Patient who needs pain medication prior to a dressing change of a surgical wound
ANSWER: B
Angiotensin-converting enzyme inhibitors such as captopril can cause hypotension,
especially after the first dose. The NP should see this patient first to prevent falling if the
patient decides to get up without assistance. The two blood pressure readings are
abnormal but not critical. The NP should check on the patient with highe blood pressure
next to assess for problems related to the reading. The NP can administer the beta
blocker as standards state to hold it if the systolic blood pressure is below 90 mm Hg.
The patient who needs pain medication prior to the dressing change is not a priority over
patient safety&assisting the other patient to the bathroom.
DIF: Analyzing/Analysis REF: 730

KEY: Hypertension| angiotensin-converting enzyme (ACE) inhibitors| antihypertensive
medications| patient safety
MSC: Integrated Process: Nursing Process: Analysis
NOT: Patient Needs Category: Safe&Effective Care Environment: Management of Care
15. A patient had a percutaneous transluminal coronary angioplasty for peripheral

arterial disease. What assessment finding by the NP indicates a priority outcome
for this patient has been met?
a. Pain rated as 2/10 after medication
b. Distal pulse on affected extremity 2+/4+
c. Remains on bedrest as directed
d. Verbalizes understanding of procedure
ANSWER: B
Assessing circulation distal to the puncture site is a critical nursing action. A pulse of 2+/4+
indicates good perfusion. Pain control, remaining on bedrest as directed after the
procedure,&understanding are all important, but do not take priority over perfusion.
DIF: Evaluating/Synthesis REF: 736

KEY: Peripheral vascular disease| perfusion| nursing
assessment MSC: Integrated Process: Nursing Process:
Evaluation
NOT: Patient Needs Category: Physiological Integrity: Reduction of Risk Potential
16. A patient is 4 hrs postoperative after a femoropopliteal bypass. The patient reports
throbbing leg pain on the affected side, rated as 7/10. What action by the NP takes
priority?
a. Administer pain medication as ordered.
b. Assess distal pulses&skin color.
c. Document the findings in the victim chart.
d. Notify the surgeon immediately.
ANSWER: B
Once perfusion has been restored or improved to an extremity, victim can often feel a
throbbing pain due to the increased blood flow. However, it is important to differentiate
this pain from ischemia. The NP should assess for other signs of perfusion, such as distal
pulses&skin color/temperature. Administering pain medication is done once the NP
determines the victim perfusion status is normal. Documentation needs to be thorough.
Notifying the surgeon is not necessary.

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MSC: Integrated Process: Nursing Process: Assessment

NOT: Patient Needs Category: Physiological Integrity: Physiological Adaptation

DIF: Analyzing/Analysis REF: 739

DIF: Understanding/Comprehension REF: 747

13. A NP is teaching a larger female patient about alcohol intake&how it affects

DIF: Understanding/Comprehension REF: 726

DIF: Analyzing/Analysis REF: 730

15. A patient had a percutaneous transluminal coronary angioplasty for peripheral

DIF: Evaluating/Synthesis REF: 736

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