arterial insufficiency. What assessment finding should the nurse identify as most consistent with this diagnosis? A) Dry, shiny, hairless shins and feet 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. B) Hair loss on the legs may be an age-related change rather than a sign of arterial insufficiency. 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. D) The client's toe is receiving an inadequate supply of blood. 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. C) Document the finding and proceed with the assessment. 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. C) Hold the probe at a 60- to 90-degree angle to the client's skin. D) Push the probe firmly against the skin to enhance audibility. Page 6 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? A) Ulnar 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. B) Document the lack of patency in the ulnar and/or radial arteries. 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.
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- Spring '17
- Nursing, pulse, intercostal space