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1. The nurse has finished receiving the morning change-of-shift report.

Which client should the nurse assess first?


1. The client diagnosed with arterial occlusive disease who has intermittent claudication.
2. The client on strict bed rest who is complaining of calf pain and has a reddened calf.
3. The client who complains of low back pain when lying supine in the bed.
4. The client who is upset because the food doesn’t taste good and is cold all the time.

2. The nurse is caring for clients on a vascular disorder unit. Which laboratory data warrant immediate intervention by the nurse?
1. The PTT of 98 seconds for a client diagnosed with deep vein thrombosis (DVT).
2. The hemoglobin 11.4 for a client diagnosed with Raynaud’s phenomenon.
3. The white blood cell (WBC) count of 11,000 for a client with a stasis venous ulcer.
4. The triglyceride level of 312 mmol/L in a client diagnosed with hypertension (HTN).

3. The unlicensed assistive personnel (UAP) tells the nurse the client has a blood pressure of 78/46 and a pulse of 116 using a vital signs
machine. Which intervention should the nurse implement first?
1. Notify the healthcare provider immediately.
2. Have the UAP recheck the client’s vital signs manually.
3. Place the client in Trendelenburg position.
4. Assess the client’s cardiovascular status.
4. The charge nurse on a vascular unit is working with a new unit secretary. Which statement concerning laboratory data is most
important for the charge nurse to tell the unit secretary?
1. “Be sure to show me any lab information that is called in to the unit.”
2. “Make sure to file the reports on the correct client’s chart.”
3. “Do not take any laboratory reports over the telephone.”
4. “Verify all telephone reports by calling back to the lab.”

5. The nurse on the vascular unit is preparing to administer medications to clients on a medical unit. Which medication should the nurse
question administering?
1. Vitamin K (AquaMephyton), a vitamin, to a client with an International Normal Ratio (INR) of 2.8.
2. Propranolol (Inderal), a beta-adrenergic, to a client with arterial hypertension.
3. Nifedipine (Procardia), a calcium channel blocker, to a client with Raynaud’s disease.
4. Enalapril (Vasotec), an angiotensin-converting enzyme (ACE) inhibitor, to a client with a sodium level of 138 mEq/L.

6. The nurse has received the shift report. Which client should the nurse assess first?
1. The client with a deep vein thrombosis who is complaining of dyspnea and coughing.
2. The client diagnosed with Buerger’s disease who has intermittent claudication.
3. The client diagnosed with an aortic aneurysm who has an audible bruit.
4. The client with acute arterial ischemia who has bilateral palpable pedal pulses.

7. The female client diagnosed with atherosclerosis tells the clinic nurse her stomach hurts after she takes her morning medications. The
client is taking a calcium channel blocker, a daily aspirin, and a statin. Which intervention should the nurse implement first?
1. Assess the client for abnormal bleeding.
2. Instruct the client to stop taking the aspirin.
3. Recommend the client take an enteric-coated aspirin.
4. Instruct the client to notify the HCP.

8. The nurse educator on a vascular unit is discussing delegation guidelines to a group of new graduates. Which statement from the group
indicates the need for more teaching?
1. “The UAP will be practicing on my brand-new nursing license.”
2. “I will still retain accountability for what I delegate to the UAP.”
3. “I must make sure the UAP to whom I delegate is competent to perform the task.”
4. “When I delegate, I must follow up with the UAP and evaluate the task.”

9. The nurse is reviewing the literature to identify evidence-based practice research that supports a new procedure using a new product
when changing the central line catheter dressing. Which research article would best support the nurse’s proposal for a change in the
procedure?
1. The article in which the study was conducted by the manufacturer of the product used.
2. The research article that included 10 subjects participating in the study.
3. The review-of-literature article that cited ambiguous statistics about the product.
4. The review-of-literature article that cited numerous studies supporting the product.

10. The nurse and the unlicensed assistive personnel are caring for clients on a vascular unit. Which task is most appropriate for the nurse
to delegate?
1. Provide indwelling catheter care to a client on bed rest.
2. Evaluate the client’s 8-hour intake and output.
3. Give a bath to the client who is third-spacing.
4. Administer a cation-exchange resin enema to a client.
11. The nurse asks the female UAP to apply the sequential compression devices (SCDs) to a client who is on strict bed rest. The UAP
tells the nurse that she has never done this procedure. Which action would be priority for the nurse to take?
1. Tell another UAP to put the SCDs on the client.
2. Demonstrate the procedure for applying the SCDs.
3. Perform the task and apply the SCDs to the client.
4. Request the UAP watch the video demonstrating this task.

12. The nurse in the vascular critical care unit is working with an LPN who was pulled to the unit as a result of high census. Which task
is most appropriate for the nurse to assign to the LPN?
1. Assess the client who will be transferred to the medical unit in the morning.
2. Administer a unit of blood to the client who is 1 day postoperative.
3. Hang the bag of heparin for a client diagnosed with a pulmonary embolus.
4. Assist the HCP with the insertion of a client’s Swan-Ganz line.

13. The nurse is administering one unit of packed red blood cells to a client. Fifteen minutes after initiation of the blood transfusion, the
client becomes restless and complains of itching on the trunk and arms. Which intervention should the nurse implement first?
1. Assess the client’s vital signs.
2. Notify the HCP.
3. Maintain a patent IV line.
4. Stop the transfusion at the hub.

14. The staff nurse on a vascular disorder unit asks the charge nurse, “What should I be looking for when I read a research article?”
Which response indicates the charge nurse does not understand how to read a nursing research article?
1. “You should be able to determine why the research was done.”
2. “You should look to find out how much money was used for the study.”
3. “You should evaluate which research method was used for the study.”
4. “You should read the method section to find out what setting was used.”

15. The nurse calls the HCP for an order for pain medication for a client who is 2 days postoperative aortic aneurysm repair. The HCP
gives the nurse an order for “Demerol 50 mg IVP now and then every 4 hours as needed.” Which action should the nurse implement
first?
1. Write the order in the chart with the words “per telephone order (TO).”
2. Request another nurse to verify the HCP’s order on the phone.
3. Read back the order to the HCP before hanging up the phone.
4. Transcribe the order to the medication administration record.

16. The charge nurse on the vascular unit is reviewing laboratory blood work. Which result warrants intervention by the charge nurse?
1. The client whose INR is 2.3.
2. The client whose H&H is 11 g/dL and 36%.
3. The client whose platelet count is 65,000 per milliliter of blood.
4. The client whose red blood cell count is 4.8 × 10 mm6.

17. A client on the vascular unit tells the day shift primary nurse that the night nurse did not answer the call light for almost 1 hour.
Which statement would be most appropriate by the day shift primary nurse?
1. “The night shift often has trouble answering the lights promptly.”
2. “I am sorry that happened and I will answer your lights promptly today.”
3. “I will notify my charge nurse to come and talk to you about the situation.”
4. “There might have been an emergency situation so your light was not answered.”

18. The nurse is preparing to administer a unit of packed red blood cells to an elderly client who is 1 day postoperative abdominal aortic
aneurysm. Which interventions should the nurse implement? List in order of performance.
1. Obtain the unit of blood from the blood bank.
2. Start an IV access with normal saline at a keep-open rate.
3. Have the client sign the permit to receive blood products.
4. Check the unit of blood with another nurse at the bedside.
5. Initiate the transfusion at a slow rate for 15 minutes.

19. The elderly client diagnosed with deep vein thrombosis is complaining of chest pain during inhalation. Which intervention should the
nurse implement first?
1. Ask the HCP to order a stat lung scan.
2. Place oxygen on the client via nasal cannula.
3. Prepare to administer intravenous heparin.
4. Tell the client not to ambulate and remain in bed.

20. Which laboratory data should the nurse in the long-term care unit notify the healthcare provider about?
1. The client receiving digoxon who has a digoxin level of 2.6.
2. The client receiving enoxaparin (Levonox) who has a PT of 12.9 seconds.
3. The client receiving ticlopidine (Ticlid) who has a platelet count of 160,000.
4. The client receiving furosemide (Lasix) who has a potassium level of 4.2 mEq/L.

21. The occupational nurse is caring for the client who just severed two fingers from the right hand. Which intervention should the
occupational nurse implement first?
1. Place the severed fingers in a sterile cloth and then in an ice chest.
2. Instruct the client to elevate the right arm over the heart.
3. Don non-sterile gloves on both hands.
4. Apply direct pressure to the right radial pulse.

22. The clinic nurse is making assignments to the staff. Which assignment/delegation is most appropriate?
1. Request the LPN to escort the client to the examination room.
2. Ask the unlicensed assistive personnel (UAP) to prepare the room for the next client.
3. Instruct the RN to administer the tetanus shot to the client.
4. Tell the clinic secretary to call in a new prescription for a client.

23. The female client tells the charge nurse the unlicensed assistive personnel (UAP) did not know how to take her blood pressure.
Which action should the charge nurse implement first?
1. Discuss the client’s comment with the UAP.
2. Retake the BP and inform the client of her BP reading.
3. Explain that the UAP knows how to take a BP reading.
4. Ask the UAP to demonstrate taking a BP reading.

24. Which medication is most appropriate for the nurse to assign to the LPN to administer?
1. The intravenous push antiemetic to the client who is nauseated and vomiting.
2. The subcutaneous low-molecular-weight heparin to the client with a pulmonary embolus.
3. The PO pentoxifylline (Trental) to the client who has intermittent claudication.
4. The sublingual nitroglycerin to the client who is complaining of chest pain.

25. The clinic nurse is assessing a client who is complaining of right leg calf pain. The right calf is edematous and warm to the touch.
Which intervention should the nurse implement first?
1. Notify the clinic HCP immediately.
2. Ask the client how long the leg has been hurting.
3. Complete a neurovascular assessment on the leg.
4. Place the client’s right leg on two pillows.

26. The fire alarm starts going off in the family practice clinic. Which action should the nurse take first?
1. Determine whether there is a fire in the clinic.
2. Evacuate all the people from the clinic.
3. Immediately call 911 and report the fire.
4. Instruct clients to stay in their rooms and close the doors.

27. The female unlicensed assistive personnel (UAP) tells the clinic nurse, “One of the medical interns asked me out on a date. I told him
no but he keeps asking.” Which
statement is the nurse’s best response?
1. “I will talk to the intern and tell him to stop.”
2. “Did anyone hear the intern asking you out?”
3. “He asks everyone out; that is just his way.”
4. “You should inform the clinic’s director of nurses.”
28. The clinic nurse overhears another staff nurse telling the pharmaceutical representative,
“If you bring us lunch from the best place in town, I will make sure you get to see the
HCP.” Which action should the clinic nurse take?
1. Tell the pharmaceutical representative the staff nurse’s statement was inappropriate.
2. Report this behavior to the clinic’s director of nurses immediately.
3. Do not take any action and wait for the food to be delivered.
4. Inform the HCP of the staff nurse’s and pharmaceutical representative’s behaviors.

29. The home health (HH) nurse in the office is notified the female client on warfarin (Coumadin), an oral anticoagulant, has
an International Normalized Ratio (INR) of
3.8. Which action should the HH nurse implement first?
1. Document the result of the INR in the client’s chart.
2. Contact the client and ask whether or not she has any abnormal bleeding.
3. Notify the client’s healthcare provider of the INR results.
4. Schedule an appointment with the client to draw another INR.

30. The home health (HH) nurse is caring for a client with arterial hypertension who has had a cerebrovascular accident. Which priority
intervention should the nurse discuss with the client when teaching about arterial hypertension?
1. Discuss the importance of the client adhering to a low-salt diet.
2. Explain the need for the client to take antihypertensive medications as prescribed.
3. Tell the client to check and record their blood pressure readings daily.
4. Encourage the client to walk at least 30 minutes three times a week.

31. Which action by the unlicensed assistive personnel (UAP) indicates to the nurse the UAP understands the correct procedure for
applying compression stockings to the client recovering from a pulmonary embolus?
1. The UAP instructs the client to sit in the chair when applying the stockings.
2. The UAP cannot insert one finger under the proximal end of the stocking.
3. The UAP ensures the toe opening is placed on the top side of the feet.
4. The UAP checked to make sure the client’s toes were warm after putting the stockings on.

32. The home health (HH) nurse enters the yard of a client and is bitten on the leg by the client’s dog. Which intervention should the
nurse implement first?
1. Clean the dog bite with soap and water and apply antibiotic ointment.
2. Obtain the phone number and contact the client’s veterinarian.
3. Contact the HH care agency and complete an occurrence report.
4. Ask the client whether the dog has had all the required vaccinations.
33. The nurse on the vascular unit is caring for a client diagnosed with arterial occlusive disease. Which statement by the client warrants
immediate intervention by the nurse?
1. “My legs start to hurt when I walk to check my mail.”
2. “My legs were so cold I had to put a heating pad on them.”
3. “I hang my legs off the side of my bed when I sleep.”
4. “I noticed that the hair on my feet and up my leg is gone.”

34. The home health (HH) nurse has completed a home assessment on a client and finds out there are no smoke detectors in the home.
The client tells the nurse they just cannot afford them. Which action should the nurse implement first?
1. Purchase at least one smoke detector for the client’s home.
2. Notify the HH care agency social worker to discuss the situation.
3. Ask the client whether a family member could buy a smoke detector.
4. Contact the local fire department to see if they can provide smoke detectors for the client.

35. The nurse is admitting a 72-year-old female client and notes multiple bruises on the face, arms, and legs along with possible cigarette
burns on her upper arms. The client states she fell on an ashtray and doesn’t want to talk about it. Which nursing intervention is priority?
1. Document the objective findings in the client’s chart.
2. Tell the client she must talk about the situation with the nurse.
3. Report the situation to the Adult Protective Services.
4. Take photographs of the bruises and cigarette burns.

36. The nurse is admitting a client diagnosed with deep vein thrombosis (DVT) in the right leg. Which statement by the client warrants
immediate intervention by the nurse?
1. “I take a baby aspirin every day at breakfast.”
2. “I have ordered myself a medical alert bracelet.”
3. “I eat spinach and greens at least twice a week.”
4. “I got a new recliner so I can elevate my legs.”

37. The male client with peripheral vascular disease tells the nurse, “I know my foot is really bad. My doctor told me I don’t have any
choice and I must have an amputation, but I don’t want one.” Which action supports the nurse being a client advocate?
1. Support the medical treatment, and recommend the client have the amputation.
2. Recommend the client talk to his wife and children about his decision.
3. Explain to the client that he has a right to a second opinion if he doesn’t want an amputation.
4. Tell the client she will go with him to discuss his decision with the doctor.

38. The charge nurse observes the unlicensed assistive personnel (UAP) crying after the death of a client. Which is the charge nurse’s
best response to the UAP?
1. “If you cry every time a client dies, you won’t last long on the unit.”
2. “It can be difficult when a client dies. Would you like to take a break?”
3. “You need to stop crying and go on about your responsibilities.”
4. “Did you not realize that clients die in a healthcare facility?”

39. The nursing staff confronts the hospice nurse overseeing the care of a client in a longterm care facility. The nursing staff wants to
send the client who is diagnosed with gangrene of the left leg secondary to peripheral occlusive disease to the hospital for
treatment. Which intervention should the nurse implement first?
1. Check with the client to see whether or not the client wants to go to a hospital.
2. Explain that the client can be kept comfortable at the long-term care facility.
3. Discuss the hospice concept of comfort measures only with the staff.
4. Call a client care conference immediately to discuss the conflict.

40. The client diagnosed with an abdominal aortic aneurysm died unexpectedly, and the nurse must notify the significant other. Which
statement made by the nurse is the best over the telephone?
1. “I am sorry to tell you, but your loved one has died.”
2. “Could you come to the hospital? The client is not doing well.”
3. “The HCP has asked me to tell you of your family member’s death.”
4. “Do you know whether the client wished to be an organ donor?”

41. The nurse has been pulled from a medical unit to work on the vascular unit for the shift. Which client should the charge nurse assign
to the medical unit nurse?
1. The client with the femoral-popliteal bypass who has paraesthesia of the foot.
2. The client with an abdominal aortic aneurysm who is complaining of low back pain.
3. The client newly diagnosed with chronic venous insufficiency who needs teaching.
4. The client with varicose veins who is complaining of deep, aching pain of the legs.
42. The charge nurse in the vascular intensive care unit assigns three clients to the staff nurse. The staff nurse thinks this is an unsafe
assignment. Which action should the staff nurse implement first?
1. Refuse to take the assignment and leave the hospital immediately.
2. Tell the supervisor that he or she is concerned about the unsafe assignment.
3. Document his or her concerns in writing and give it to the supervisor.
4. Take the assignment for the shift but turn in his or her resignation.

43. At 2230, the nurse is preparing to administer pain medication to a male client who rates his pain as a 4 on the numeric pain scale.
Which medication should the nurse administer?
1. Administer morphine 2 mg IVP.
2. Administer promethazine 12.5 mg IVP.
3. Administer hydrocodone 5 mg PO.
4. Administer ibuprofen 600 mg PO.

44. The matriarch of a family has died on the vascular unit. The family tells the nurse the daughter is coming to the hospital from a
nearby city to see the body. Which intervention should the nurse implement?
1. Plan to allow the daughter to see the client in the room.
2. Take the client to the morgue for the daughter to view.
3. Request the family call the daughter and tell her not to come.
4. Explain to the daughter that the unit is too busy for family visitation.

45. The unit manager on the vascular unit is planning a change in the way post-mortem care is provided. Which is the first step in the
change process?
1. Collect data.
2. Identify the problem.
3. Select an alternative.
4. Implement a plan.

46. The nurse is preparing to administer the third unit of packed red blood cells (PRBCs)
to a client with a ruptured aortic aneurysm. Which interventions should the nurse
implement? Select all that apply.
1. Hang a bag of D5NS to keep open (TKO).
2. Change the blood administration set.
3. Check the client’s current vital signs.
4. Assess for allergies to blood products.
5. Obtain a blood warmer for the blood.

47. The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a vascular unit. Which task should the nurse
delegate to the UAP?
1. Apply bilateral sequential compression devices to the client with deep vein thrombosis.
2. Accompany the client with thromboangiitis obliterans outside to smoke a cigarette.
3. Elevate the leg of the client who is one day postoperative femoral-popliteal bypass.
4. Perform Doppler studies on the client with right upper extremity lymphedema.

48. The charge nurse on a vascular postsurgical unit observes a new graduate telling an elderly client’s spouse not to push the client’s
patient-controlled analgesia (PCA) pump button. Which action should the charge nurse implement?
1. Encourage the visitor to push the button for the client.
2. Ask the nurse to step into the hallway to discuss the situation.
3. Discuss the hospital protocol for the use of PCA pumps.
4. Continue to perform the charge nurse’s other duties.

49. Which client should the nurse assess first after receiving the shift report?
1. The client with a right above-the-knee amputation who is complaining of right foot pain.
2. The client with arterial hypertension who is complaining of a severe headache.
3. The client with lymphedema who has 4+ pitting edema of the left lower leg.
4. The client with gangrene of the right foot who has a foul-smelling discharge.

50. The nurse observes an LPN crushing nifedipine (Procardia XL) before administering the medication to a client with arterial
hypertension who has difficulty swallowing pills. Which intervention should the nurse implement first?
1. Tell the LPN to take the client’s blood pressure.
2. Take no action since this is appropriate behaviour.
3. Show the LPN where to find pudding for the client.
4. Tell the LPN this medication cannot be crushed.