Ch22 Assessing Peripheral Vascular System PDF

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how to assess periphral vascular, check capillary refill...

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Chapter 22 Assessing Peripheral Vascular System 1. During a client's vascular assessment, the nurse is palpating the pulse just under the client's inguinal ligament. The nurse is assessing which pulse? A) Temporal B) Brachial C) Popliteal

2. During a health visit, a client says, ìI know that arteries and veins are both blood vessels, but what's the difference?î Which of the following would the nurse include in the response? B) Arteries carry 70% of the body's blood volume. C) Arteries have a lower pressure than veins. D) Arteries carry waste from the tissues.

3. A nurse is palpating a client's epitrochlear nodes. The nurse is palpating which area? A) Posterior neck B) Axillary area C) Inguinal area

4. An older adult client presents with cramping-type leg pain when walking, which is relieved by rest. The client also has cool, pale feet and capillary refill in the toes of 4 to 6 seconds. Which of the following would the nurse suspect? B) Musculoskeletal weakness C) Venous insufficiency D) Diabetic neuropathy

5. The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse should note the possibility of what health problem when making the referral? B) Stasis ulceration C) Arterial occlusion D) Dependent edema

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6. Which question would be most important to ask when obtaining the nursing health history of a male client with extensive peripheral vascular disease? A) ìWhat dietary supplements do you take?î B) ìWhen was your last prostate exam for cancer?î D) ìHave you had an electrocardiogram recently?î

7. When analyzing the nursing history recently taken on a client, which factor would most strongly alert the nurse to a significantly increased risk for chronic arterial insufficiency? A) Sedentary lifestyle B) A family history of arterial insufficiency C) Intake of 1 to 2 alcoholic drinks per day

8. The clinic nurse is reviewing the medication history of a 39-year-old woman. Which medication would the nurse identify as a potential risk factor for thrombophlebitis? A) A beta-adrenergic blocker B) A selective serotonin reuptake inhibitor (SSRI) D) An antilipid agent

9. The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. Which of the following would be most appropriate for the nurse to do next? A) Document ìabsence of dorsalis pedis pulse.î B) Auscultate the anatomic area with a stethoscope. D) Apply a tourniquet for 2 minutes and then reassess.

10. A nurse assesses a client's capillary refill and finds it to be less than 2 seconds. Which of the following should the nurse do next? B) Recheck in 5 minutes after elevating the arm. C) Reassess after applying warm compresses. D) Refer the client for medical follow-up.

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11. A nurse is unable to palpate a client's radial and ulnar pulses. What is the nurse's most appropriate action? A) Refer the client for medical follow-up. B) Document the finding and proceed with the assessment. D) Auscultate the apical pulse.

12. A nurse assesses a client's epitrochlear nodes and finds them to be enlarged and tender. Which of the following would the nurse do next? A) Ask the client about any recent ear and throat infections. B) Carefully assess the cervical lymph nodes for enlargement. D) Assess both legs for Homans' sign.

13. Assessment of a client's lower extremities reveals unilateral edema of the right foot and ankle. Which of the following would be most appropriate for the nurse to do next? B) Perform the Allen test. C) Check for bilateral varicosities. D) Palpate the femoral pulses.

14. When assessing a client for possible varicose veins, the nurse should do which of the following actions? B) Tell the client to raise his or her leg. C) Dorsiflex the client's foot. D) Obtain the ankle-brachial index.

15. A group of nursing students is reviewing information about the lymph nodes of the lower extremity and the areas drained by them. The students demonstrate the need for additional teaching when they identify which area as being drained by the superficial inguinal nodes? A) Legs B) External genitalia D) Buttocks

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16. A nurse instructor is observing a nursing student assess a client's capillary refill. Which action by the student indicates the proper technique? A) Student gently compresses the wrist area on the side of the thumb. C) Student applies firm pressure to the hand, noting any indentation. D) Student asks client to turn hands slowly over and back.

17. A nurse is determining a client's ankle-brachial index. Which result would indicate to the nurse that the client's circulation is normal and free of arterial occlusion? A) 0.5 B) 0.8 D) 1.4

18. Assessment of a client's radial pulse reveals that it is bounding and does not disappear with moderate pressure. The nurse documents the pulse amplitude as which of the following? A) 1+ B) 2+ D) 4+

19. A nurse obtains the following information: right arm brachial pressure, 160 mm Hg; left arm brachial pressure, 150 mm Hg; right ankle pressure, 80 mm Hg; left ankle pressure, 94 mm Hg. The nurse determines that the right ankle-brachial index would be which of the following? B) 0.53 C) 0.59 D) 0.63

20. While inspecting the lower extremities of a client, the nurse observes an ulcer. Which of the following would lead the nurse to suspect that the ulcer is the result of arterial insufficiency? Select all that apply. A) Irregular border

D) Moderate leg edema

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21. The nurse is assessing a client who has been referred to the clinic because of possible arterial insufficiency. What assessment finding should the nurse identify as most consistent with this diagnosis? B) Pitting edema to the feet and ankles C) Numbness and tingling of the lower extremities D) Reddish-blue coloration of the shins and feet

22. The nurse is assessing an 81-year-old client's peripheral vascular function. What principle should guide the nurse's analysis of assessment data? A) Leg pain that is relieved by rest is the result of normal physiological changes.

C)

Venous ulcers and arterial ulcers have a similar appearance and course in older adults. D) Non-palpable peripheral pulses are expected in clients over the age of 80.

23. The nurse's inspection of a client's extremities reveals a deep, circular, painful wound on the client's great toe. What should the nurse suspect as the etiology of the client's wound? A) Blood is returning from the client's toe more slowly than normal. B) There is a blockage or infection in the client's lymphatic system. C) There is a disruption in osmotic pressure in the client's extremities.

24. The nurse has attempted to palpate the client's popliteal pulses but is unable to feel them, despite confirming appropriate landmarking and client positioning. What is the nurse's best response? A) Advocate for a referral to a vascular surgeon. B) Have the client perform light physical activity to promote circulation and then reattempt. D) Palpate the client's brachial pulse.

25. The nurse is using Doppler ultrasound to auscultate the peripheral pulses of a client with peripheral vascular disease. What action should the nurse perform during this assessment? A) Gently cool the client's extremities to aid auscultation. B) Apply a small amount of petroleum gel to the Doppler probe. D) Push the probe firmly against the skin to enhance audibility.

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26. The nurse is performing a peripheral vascular assessment of an adult client. The nurse is palpating the client's peripheral pulses but knows that some are not palpable, even in healthy clients. What pulse is not palpable in a large proportion of healthy clients? B) Radial C) Brachial D) Femoral

27. The nurse is performing the Allen test on a client who has a diagnosis of peripheral vascular disease. What action should the nurse take after a positive Allen test? A) Document the absence of dorsalis pedis or posterior tibial pulses. C) Attempt to palpate the popliteal pulse with the client's leg in a dependent position. D) Corroborate the finding by assessing capillary refill in the client's great toes.

28. The nurse's inspection of a Caucasian client's lower extremities reveals a brownish coloration to the client's ankles and shins. The nurse should perform further assessments that address what health problem? B) Peripheral edema C) Coronary artery disease D) Raynaud's phenomenon

29. The nurse reads in a client's electronic health record that her most recent ankle-brachial index (ABI) was 0.42. How should this assessment finding inform the nurse's care? A) The nurse should inspect the client's feet and ankles for venous ulcers once per shift. C)

The nurse should assess the client's extremities for pitting edema at least once per shift. D) The nurse should position the client to promote venous return.

30. The presence of faint pedal pulses in a client has prompted the nurse to perform a position change test for arterial insufficiency. What finding would suggest that the client may have arterial insufficiency? A) The client's legs are tender on palpation when in a dependent position. C) The client's legs return to a pink color in 5 seconds. D) The client's legs develop pitting edema when he or she dangles them over the bedside.

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Answer Key 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30.

D A D A A C D C C A C C A A C B C C A B, C, E A B D C C A B A B B

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