Assessing the Peripheral (1)
A client with peripheral vascular disease is discharged from the health care facility. Which risk reduction teaching tip should the nurse discuss during discharge teaching?
A) Avoid smoking.
B) Decrease dietary fiber intake.
C) Limit physical activity.
D) Eat a low-protein diet.
A nurse cares for a client who is postoperative cholecystectomy. Which action by the nurse is appropriate to help prevent the occurrence of venous stasis?
A) Assist in active range-of-motion exercise of the upper body.
B) Assist the client to walk as soon and as often as possible.
C) Massage lower extremities vigorously every 6 hours.
D) Raise the foot of the bed for an hour and then lower it.
The nurse documents a 2+ radial pulse. What assessment data indicated this result?
A) bounding pulse
B) diminished pulse
C) absent (unable to palpate) pulse
D) brisk, expected (normal) pulse
Which area of the arm drains to the epitrochlear nodes?
A) Radial surface of the forearm and hand, thumb and index finger, and radial middle finger
B) Ulnar surface of the forearm and hand; second, third, and fourth fingers
C) Ulnar surface of the forearm and hand, little and ring fingers, and ulnar middle finger
D) Radial surface of the forearm and hand; second, third, and fourth fingers
A nurse receives an order to perform a compression test to assess the competence of the valves in a client's varicose veins. Which action by the nurse demonstrates the correct way to perform this test?
A) Firmly compress the lower portion of the varicose vein.
B) Place the second hand 3 to 4 inches above the first hand.
C) Feel for a pulsation to the fingers in the lower hand.
D) Ask the client to sit on a chair for the examination.
The nurse is providing care for a 61-year-old female smoker who is 30 kg overweight and was diagnosed with type 2 diabetes several years prior. Which of the following teaching points regarding the prevention of peripheral artery disease (PAD) is most accurate?
A) "I'll show you how to check your pulses at your groin, knees and feet to monitor your risk of PAD."
B) "It's critical that you come to get screening tests twice annually."
C) "If you develop swelling in your ankles or feet, then you should seek emergency care."
D) "Quitting smoking and keeping good control of your blood sugar levels are important."
A client with a right subclavian central line develops fever of 101.0 degrees Fahrenheit. What is the nurse's best action?
A) Discontinue the central line.
B) Check the insertion site for redness.
C) Culture the tip of the central line.
D) Flush all ports with heparin solution.
A nurse recognizes that a common complication of vascular surgery may manifest as which assessment finding?
A) Tenderness on plantar flexion
B) Pallor of the leg on elevation
C) Pain in the calf muscles
D) Cramping pain in both thighs
A nurse assesses the peripheral vascular system of a client who is in the supine position. What further assessment should the nurse perform if unable to palpate the left popliteal pulse?
A) Palpate the right leg with the client in supine position.
B) Assist the client to the prone position and palpate again.
C) Elevate and palpate the left leg in supine position.
D) Place the client in the lateral position and palpate.
A nurse recognizes which finding as an indication of an ulcer due to arterial insufficiency?
A) Painful ulcer with irregular border
B) Moderate to severe leg edema
C) Deep ulcers that often involve joint space
D) Ulcer commonly located in anterior tibial area
A nurse assesses capillary refill time in a client and finds it to be less than 2 seconds. What is an appropriate action by the nurse?
A) Dangle the arms and recheck in 5 minutes.
B) Apply a warm compress to both hands.
C) Obtain a blood pressure in both arms.
D) Document the finding as normal.
A nurse palpates a weak left radial artery on a client. What should the nurse do next?
A) Palpate the left ulnar artery.
B) Document the finding in the client's record.
C) Palpate both radial arteries for symmetry.
D) Assess the left hand for pallor and coolness.
A nurse recognizes that what change is considered normal in the lymphatic system of the elderly?
A) Lymph nodes are smaller and fewer in number.
B) Tenderness is common, especially in the lower extremities.
C) Irregularity of shape and size increase with age.
D) Swelling occurs more frequently and lasts longer.
Before beginning the assessment of the peripheral vascular system, a nurse should take what action to best facilitate the exam and ensure accurate results?
A) Make sure the temperature in the room is comfortable.
B) Place the client in a position of comfort for the entire exam.
C) Ensure proper lighting in the room.
D) Allow client to empty the bladder.
A nurse experiences difficulty with palpation of the dorsalis pedis pulse in a client with arterial insufficiency. What is an appropriate action by the nurse based on this finding?
A) Assess adequacy of blood flow using a Doppler device.
B) Attempt to palpate the posterior tibial pulse.
C) Check the extremity for findings of decreased blood flow.
D) Obtain an order for ankle brachial index test to be performed
A client tells a nurse that she has been experiencing intermittent episodes of numbness, tingling, pain, and burning in the fingertips, especially after being cold. What is an appropriate question for the nurse to ask the client to further assess this occurrence?
A) "Have you started any new medications?"
B) "Are you exercising when this occurs?"
C) "Do you have a history of cardiovascular disease?"
D) "Do you notice your fingers changing colors?"
Which statement demonstrates correct technique by a nurse when using the Doppler device to locate peripheral pulses?
A) Warming the gel will help to avoid vasoconstriction at the site.
B) Avoid marking the skin because this will interfere with sound transmission.
C) Press the device firmly against the skin to ensure good contact.
D) Use a 90-degree angle to avoid dampening the sound waves.
Which statement describes the correct technique by a nurse when performing the ankle-brachial pressure index test?
A) Inflate the blood pressure cuff 40-50 mm Hg beyond where the last signal was heard.
B) Quickly deflate the blood pressure cuff to allow blood to return to the extremity.
C) Use a blood pressure cuff that is 20% wider than the diameter of the client's limb.
D) Record the last signal that is auscultated as the ankle pressure.
A nurse performs the Allen test to evaluate the patency of the radial and ulnar arteries for a client who is to undergo a radial artery puncture. What precaution should the nurse take to prevent a false-positive test?
A) Ensure that the client's hand is not opened in exaggerated extension
B) Have the client rest the hand palm side up and make a fist
C) Use the thumbs to occlude the radial and ulnar arteries
D) Keep both arteries occluded and have the client release the fist
A nurse palpates the presence of an enlarged epitrochlear lymph node. Which area of the client's body should the nurse thoroughly examine to assess for the source of this finding?
A) Abdomen, noting any organ enlargement or tenderness
C) Head and neck for recent ear infection or sore throat
D) Cervical lymph nodes for tenderness and swelling
B) Lower arm and hand for erythema and swelling
A nurse inspects the lower extremities of a client and notices that the legs appear asymmetric. What should the nurse do first in regards to this finding?
A) Notify the health care provider
B) Assess for the presence of pitting edema
C) Palpate for temperature in the feet
D) Measure the diameter of the calves
A client has been diagnosed with venous insufficiency. Which of the following findings should the nurse expect on interviewing this client?
A) Shiny skin, with loss of hair over the lower legs
B) Cold, pale skin on the extremities
C) Warm skin and brown pigmentation around the ankles
D) Clammy skin on the extremities
On questioning a client with peripheral edema during an interview, the nurse learns that the client has a sedentary job and drinks little water throughout the day. What underlying condition is the client most likely to have, based on these findings?
A) Deep vein thrombosis
B) Varicose veins
C) Systemic bacterial infection
D) Peripheral artery disease
A client presents with lymphedema in one arm, with nonpitting edema. Which of the following should the nurse assess for, based on this finding?
A) Presence of deep vein thrombosis
B) History of breast surgery
C) Presence of peripheral artery disease
D) History of Raynaud's disorder
A nurse palpates a client's hands and fingers. Which of the following findings would be consistent with arterial insufficiency?
A) Cool skin
B) Epitrochlear lymph nodes not palpable
C) Capillary refill time of 2 seconds
D) Bilateral radial pulses of 2+
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