Page 3 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. C) Palpate the brachial pulse. 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 . C) Examine the lower arm and hand for infection sites. 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 ? A) Compare measurements of both extremities. 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? A) Have the client stand for the exam. 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 C) Upper abdomen D) Buttocks Page 4 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. B) Student compresses the client's nail bed until it blanches. 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 C) 1.1 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+ C) 3+ 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? A) 0.50 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 B) Deep C) Circular in shape D) Moderate leg edema E) Client report of severe pain Page 5 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
- Spring '17
- Nursing, pulse, intercostal space