NU273 Week 3 PrepU: Assessing the Peripheral Vascular System

A client diagnosed with intermittent claudication wonders why the nurse wants to know where the client is experiencing cramping when walking. What would be the nurse's best answer? "The area of cramping indicates whether you may have numbness and tingling also." "The area of pain can help us identify what risk factor is predominant." "The area of pain tells us what treatment will work best for you." "The area of cramping is close to the area of arterial occlusion."

"The area of cramping is close to the area of arterial occlusion." Explanation: The area of cramping in arterial disease, termed intermittent claudication, closely approximates the level of arterial occlusion. The other options are distracters to the question. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 468

What is a long-term complication of peripheral vascular disease? Metabolic changes Amputation Diabetes mellitus Thickened skin

Amputation Explanation: Diseases of the peripheral vascular system, peripheral arterial disease, venous stasis, and thromboembolic disorders can severely affect the lifestyle and quality of life of clients. Identifying modifiable risk factors and providing health promotion counseling can prevent or delay long-term complications, such as decreased mobility and amputation. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 471

A 68-year-old retired truck driver comes to the office for evaluation of swelling in his legs. He is a smoker and has been taking medications to control his hypertension for the past 25 years. The nurse is concerned about the client's risk for peripheral vascular disease. Which of the following tests is appropriate to order to initially evaluate for this condition? PET scan Venogram CT scan of the lower legs Ankle-brachial index (ABI)

Ankle-brachial index (ABI) Explanation: The ABI is a good test for obtaining information about significant stenosis in the vessels of the lower extremities. Approximately 16% of clients with known peripheral vascular disease also have coronary artery disease. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 471

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? Attempt to palpate the posterior tibial pulse. Check the extremity for findings of decreased blood flow. Assess adequacy of blood flow using a Doppler device. Obtain an order for ankle brachial index test to be performed.

Assess adequacy of blood flow using a Doppler device. Explanation: Arterial insufficiency causes a decrease in the amount of blood flow to an extremity. If the blood flow is diminished significantly, the adequacy of the pulse may also diminish. Therefore, if a pulse cannot be palpated, the nurse's best action is to obtain a Doppler device to assess for adequate blood flow. A Doppler device works by transmitting ultra-high-frequency sound waves in a way that they strike red blood cells in an artery or vein. This rebounding ultrasound waves produces a whooshing sound that is transmitted through the Doppler. Attempting to palpate the posterior tibial pulse does not provide information about the dorsalis pedis pulse. Checking the extremity for findings of decreased blood flow is not necessary because the nurse is already aware that the client has arterial insufficiency and needs to determine the extent, not the presence, of the disease. The ankle brachial index is a much more complex test that can be performed after the Doppler determines whether or not a pulse is present. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 471

A client with a right subclavian central line develops fever of 101.0 degrees Fahrenheit. What is the nurse's best action? Discontinue the central line. Check the insertion site for redness. Culture the tip of the central line. Flush all ports with heparin solution.

Check the insertion site for redness. Explanation: Fever above 100.4 degrees Fahrenheit can indicate a central-line associated bloodstream infection for this client. The nurse should assess the insertion site for redness, edema, or purulent drainage and notify the healthcare provider for further treatment. Depending on the signs of infection that are present at the insertion site, the provider may discontinue the line and culture the tip. Flushing the ports with saline can assist the nurse in checking patency of the lines.

During the admission assessment, the nurse identifies the client has a history of Raynaud's. What assessment finding would the nurse expect to find? Cool legs bilaterally Cool leg on one side Cold fingers and hands Capillary refill less than 2 seconds

Cold fingers and hands Explanation: Raynaud's is exhibited by cold fingers and hands. Cool extremities could be due to a cool room or arterial insufficiency. A capillary refill of less than 2 seconds is normal. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 476

Which of the following assessment findings is most congruent with chronic arterial insufficiency? Ulceration on the medial surface of the client's ankle Thickened and scarred skin on the client's ankle Brown pigmentation around a client's ankles and shins Cool foot temperature and ulceration on the client's great toe

Cool foot temperature and ulceration on the client's great toe Explanation: Pigmentation, medial ankle ulceration, and thickened, scarred skin are associated with venous insufficiency, while low temperature and toe ulceration are more commonly found in cases of arterial insufficiency. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 475-478

In assessing a client, a nurse palpates her epitrochlear lymph nodes and notes that the client may have an infection in the hand or forearm. The nurse understands that which of the following are functions of the lymphatic system? Select all that apply. Traps and destroys microorganisms and foreign materials filtered from lymph Drains excess fluid and plasma proteins from tissues and returns them to the venous system Delivers oxygen, water, and nutrients to the tissues Absorbs fats from the small intestine into the bloodstream Returns blood to the heart

Drains excess fluid and plasma proteins from tissues and returns them to the venous system Traps and destroys microorganisms and foreign materials filtered from lymph Absorbs fats from the small intestine into the bloodstream Explanation: The primary function of the lymphatic system is to drain excess fluid and plasma proteins from bodily tissues and return them to the venous system. These capillaries join to form larger vessels that pass through filters known as lymph nodes. The filtering, trapping, and destruction of microorganisms, foreign materials, dead blood cells, and abnormal cells by the lymph nodes allows the lymphatic system to perform a second function as a major part of the immune system defending the body against microorganisms. A third function of the lymphatic system is to absorb fats (lipids) from the small intestine into the bloodstream. The capillaries, not the lymphatic system, deliver oxygen, water, and nutrients to the tissues. Veins, not the lymphatic system, return blood to the heart. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 466

Which of the following is an essential topic when discussing risk factors for peripheral arterial disease with a client? Exercise tolerance Extent of tobacco use and exposure Prevention of varicose veins Significance of cardiac dysrhythmias

Extent of tobacco use and exposure Explanation: Tobacco use is one of the most significant risk factors for PAD and would supersede exercise tolerance, prevention of varicose veins, or dysrhythmias. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 471

The nurse is planning care for a client recovering from orthopedic surgery. Interventions should be included to address which contributing factor to deep vein thrombosis development? Smoking Obesity Hypertension Immobility

Immobility Explanation: Immobility can lead to blood stasis, which is a contributing factor to the development of a deep vein thrombosis. Obesity is a risk factor for the development of arterial and venous disease. Smoking is a risk factor for arterial and venous disease and for the development of an abdominal aortic aneurysm. Hypertension is a risk factor for arterial disease and abdominal aortic aneurysm. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 469

A client presents to the health care clinic with a 3-week history of pain and swelling of the right foot. A nurse inspects the foot and observes swelling and a large ulcer on the heel. The client reports the right heel is very painful and he has trouble walking. Which nursing diagnosis should the nurse confirm from these data? Impaired Skin Integrity Risk for Skin Breakdown Fear of Loss of Extremity Imbalanced Nutrition

Impaired Skin Integrity Explanation: This client demonstrates Impaired Skin Integrity as evidenced by the ulcer on his heel. With the location and the presence of pain, this is most likely to be an ulcer of arterial insufficiency. The client has not verbalized any fear at this time. With the existing skin breakdown, he is not at risk because it is present. No nutritional imbalances are documented. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 487

Question 12 of 20 A hospitalized post-operative client exhibits edema, pain, erythema, and warmth in the right calf area. What is the nurse's best action? Assist the client to turn, cough, and deep breathe. Notify the healthcare provider. Encourage early ambulation. Discontinue the indwelling urinary catheter.

Notify the healthcare provider. Explanation: The client is exhibiting signs of venous thromboembolism. The healthcare provider should be notified immediately to prevent further complications. This condition is a national client safety concern for hospitalized clients. Early ambulation could dislodge a possible clot. Prevention of pneumonia is encouraged by turning, coughing, and deep breathing. Signs of a urinary tract infection include pain, increased white blood cells, and fever. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 468

The nurse is concerned that a client has poor circulation in the right hand. What finding caused the nurse to have this concern? Pallor when the ulnar artery is occluded Enlarged epitrochlear lymph nodes Minimal hair on the wrist and fingers Pallor when the fingers are overextended

Pallor when the ulnar artery is occluded Explanation: With arterial insufficiency or occlusion of the ulnar artery, pallor persists. This means that there is insufficient radial artery blood flow to the hand. Enlarged epitrochlear lymph nodes may indicate an infection in the hand or forearm. Hair does not normally grow on the wrist and fingers. Opening the hand into exaggerated extension may cause persistent pallor or a false-positive Allen test. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 477

A client complains of pain in the calves, thighs, and buttocks whenever he climbs more than a flight of stairs. This pain, however, is quickly relieved as soon as he sits down and rests. The nurse should suspect which of the following conditions in this client? Peripheral arterial disease Neuropathy secondary to diabetes Advanced chronic arterial occlusive disease Venous disease

Peripheral arterial disease Explanation: Intermittent claudication is characterized by weakness, cramping, aching, fatigue, or frank pain located in the calves, thighs, or buttocks but rarely in the feet with activity. These symptoms are quickly relieved by rest but reproducible with same degree of exercise and may indicate peripheral arterial disease (PAD). Leg pain that awakens a client from sleep is often associated with advanced chronic arterial occlusive disease. A lack of pain sensation may signal neuropathy in such disorders as diabetes. Heaviness and an aching sensation aggravated by standing or sitting for long periods of time and relieved by rest are associated with venous disease. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 468

The nurse assesses the client as shown. What pulse is the nurse assessing? Dorsalis pedis Femoral Posterior tibial Popliteal

Posterior tibial Explanation: The posterior tibial pulse is located in the groove between the medial malleolus and Achilles tendon. The femoral pulse is about halfway between the symphysis pubis and anterior iliac spine, just below the inguinal ligament. The popliteal pulse is located behind the knee lateral to the medial tendon. The dorsalis pedis pulse is located halfway up the foot, immediately lateral to the extensor tendon of the great toe. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 481

What creates the pressure gradient that regulates blood flow in the venous system? Select all that apply. Activity level Intraluminal valves Cardiac output Skeletal muscle contraction Respiration

Skeletal muscle contraction Respiration Intraluminal valves Explanation: A pressure gradient created by respiration, skeletal muscle contraction, and intraluminal valves regulates blood flow in the venous system. It has not been shown that cardiac output or activity level affects this pressure gradient. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 465

While assessing the peripheral vascular system of an adult client, the nurse detects cold clammy skin and loss of hair on the client's legs. The nurse suspects that the client may be experiencing venous stasis. arterial insufficiency. thrombophlebitis. varicose veins.

arterial insufficiency. Explanation: Manifestations of arterial insufficiency include intermittent claudication to sharp, unrelenting, and constant. Diminished or absent pulses. Skin in cool to cold in temperature and there is a loss of hair over the toes and dorsum of the foot. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 468

While performing a routine check-up on an 81-year-old retired grain farmer in the vascular surgery clinic, the nurse notes that he has a history of chronic arterial insufficiency. Which of the following physical examination findings of the lower extremities would be expected with this disease? Marked edema Thin, shiny, atrophic skin Normal temperature Normal pulsation

hin, shiny, atrophic skin Explanation: Thin, shiny, atrophic skin is more commonly seen in chronic arterial insufficiency; in chronic venous insufficiency the skin often has a brown pigmentation and may be thickened. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 468

After assessing pitting edema below the knee in a client, the nurse would suspect that which artery may be occluded? saphenous communicating popliteal iliofemoral

popliteal Explanation: Although normal popliteal arteries may be nonpalpable, an absent pulse may also be the result of an occluded artery. Further circulatory assessment such as temperature changes, skin-color differences, edema, hair distribution variations, and dependent rubor (dusky redness) distal to the popliteal artery assists in determining the significance of an absent pulse. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 464

During a physical examination, the nurse detects warm skin and brown pigmentation around an adult client's ankles. The nurse suspects that the client may be experiencing venous insufficiency. arterial occlusive disease. venous ulcers. ankle edema.

venous insufficiency. Explanation: Manifestations of venous insufficiency include cramping pain, thickened tough skin, and areas of hyperpigmentation around the medial and lateral malleolus. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 468

Which reading of the ankle-brachial pressure index (ABPI) should the nurse recognize as indicative of a normal healthy person? 0.75 0.15 0.25 1.00

1.00 Explanation: The ankle pressure in a healthy person is the same or slightly higher than the brachial pressure, resulting in an ABPI of approximately 1.00 or no arterial insufficiency. An ABPI of 0.25 or lower indicates severe stenosis leading to ischemia and tissue damage. An ABPI of 0.5 to 0.95 indicates mild to moderate arterial insufficiency. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 486

Which of the following wounds is most likely attributable to neuropathy? A moderately painful wound on the lateral aspect of the client's ankle A wound on a client's highly edematous ankle that is surrounded by pigmented skin A painless wound on the sole of the client's foot, which is surrounded by calloused skin A painful wound in the client's shin, which is surrounded by apparently healthy skin

A painless wound on the sole of the client's foot, which is surrounded by calloused skin Explanation: Neuropathic ulcers tend to develop on pressure points, such as the sole of the foot, and are often free of pain. Painful wounds surrounded by healthy skin are associated with arterial insufficiency and moderately painful ankle wounds surrounded by pigmented skin are often associated with venous ulcers. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 469

During an assessment, the nurse first performs the action shown. After that the nurse asks the client to sit up with their legs dangling from the edge of the table. What is the nurse assessing? Intermittent claudication Lymphedema Femoral pulse Arterial insufficiency

Arterial insufficiency Explanation: The color change test is to check for arterial insufficiency. With the client supine, the legs are elevated about 30 cm (12 in.) above the level of the heart. Then when have the client sit up and dangle the legs. Color should return to the feet and toes within 10 seconds. The superficial veins of the feet fill within 15 seconds. Return of color taking longer than 10 seconds or persistent dependent rubor indicates arterial insufficiency. This is not a technique to assess lymphedema, the femoral pulse, or intermittent claudication. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 482

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? Elevate and palpate the left leg in supine position. Palpate the right leg with the client in supine position. Assist the client to the prone position and palpate again. Place the client in the lateral position and palpate.

Assist the client to the prone position and palpate again. Explanation: If the nurse is unable to palpate the popliteal artery with the client in supine position, the nurse should assist the client to prone position and palpate again. If the nurse is still unable to palpate, a Doppler should be used. The nurse may partially raise the client's leg and place the fingers deep in the bend of the knee when in prone position, not in supine position. The nurse need not assist the client to lateral position and palpate. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 480

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? Assist in active range-of-motion exercise of the upper body. Raise the foot of the bed for an hour and then lower it. Assist the client to walk as soon and as often as possible. Massage lower extremities vigorously every 6 hours.

Assist the client to walk as soon and as often as possible. Explanation: Immobility creates an environment in which clotting (embolism formation) can be caused by venous stasis. Active exercise such as having the client ambulate as soon as possible will stimulate circulation and venous return. This reduces the possibility of clot formation. Raising the foot of the bed, vigorous massage, and active range of motion of the upper body may not prevent venous stasis. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 465

A nurse palpates a client's hands and fingers. Which of the following findings would be consistent with arterial insufficiency? Bilateral radial pulses of 2+ Cool skin Capillary refill time of 2 seconds Epitrochlear lymph nodes not palpable

Cool skin Explanation: A cool extremity may be a sign of arterial insufficiency. The other findings listed are all normal. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 468

Walking contracts the calf muscles and forces blood away from the heart. False True

False Skeletal muscle contraction helps force venous blood back to the heart Reference: Chapter 22: Assessing Peripheral Vascular System - Page 471

A nurse has just inspected a standing client's legs for varicosities. The nurse would now like to assess for suspected phlebitis. Which of the following should the nurse do next? Dorsiflex the client's foot and apply light pressure lateral to and along the side of the extensor tendon of the big toe Lightly palpate the client's leg veins for tenderness Use a Doppler ultrasound device on the client's leg Have the client sit down

Lightly palpate the client's leg veins for tenderness Explanation: To fully assess for a suspected phlebitis, lightly palpate for tenderness. The client should still be standing from the inspection of the legs. A Doppler ultrasound device is used to assess for pulses when they are difficult to palpate. Dorsiflexing the client's foot and applying light pressure along the extensor tendon of the big toe are done when palpating for the dorsalis pedis pulses. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 481

The client has a history of breast cancer with reconstructive surgery. The nurse should assess the client for what potential complication? Peripheral arterial disease Lymphedema Venous stasis Varicose veins

Lymphedema Explanation: Lymphedema can be a result of scarring injury, removal of lymph nodes, radiation or chronic infection. Peripheral arterial disease is caused by decreased arterial blood supply. Venous stasis is due to blood not moving which puts the client at risk for varicose veins. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 474

If palpable, superficial inguinal nodes are expected to be: Discrete, tender, and 2 cm in diameter Fixed, nontender, and 1.5 cm in diameter Nontender, mobile, and 1 cm in diameter Fixed, tender, and at 2.5 cm in diameter

Nontender, mobile, and 1 cm in diameter Explanation: Healthy lymph nodes are nontender and mobile. Inguinal lymph nodes can be 1 to 2 cm in diameter. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 479

When assessing the lymph system of an adult client, the nurse notes that the epitrochlear nodes are nonpalpable. What does this indicate? Possible lymphoma No lymphedema Atherosclerosis Normal finding

Normal finding Explanation: Normally, the epitrochlear nodes are not palpable. Normal palpable nodes are 2 cm or less. Nonpalpable epitrochlear nodes are not an indication of lymphoma or atherosclerosis. They are not related to lymphedema or its absence. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 476

A nurse palpates a weak left radial artery on a client. What should the nurse do next? Palpate the left ulnar artery. Document the finding in the client's record. Assess the left hand for pallor and coolness. Palpate both radial arteries for symmetry.

Palpate both radial arteries for symmetry. Explanation: Extremities should always be assessed simultaneously for symmetry. If the radial arteries are both weak, this may indicate a problem with peripheral circulation. The nurse should then assess the ulnar artery pulses to determine the presence of arterial insufficiency. The hands should be assessed for pallor and coolness, which would also be present with arterial insufficiency. All findings should be documented in the client's record. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 464

A client reports pain in the legs that begins with walking but is relieved by rest. Which condition should the nurse assess the client for? Obstruction in the femoral artery Diabetes mellitus Peripheral vascular problems Calcium deficiency

Peripheral vascular problems Explanation: The nurse should assess the client for peripheral vascular problems in both the legs. Intermittent claudication is a condition that indicates vascular deficiencies in the peripheral vascular system. In case of an acute obstruction, the leg pain would persist even when the client stopped walking. Diabetes can cause pain as a result of diabetic neuropathy, which is unrelated to walking. Low calcium level may cause leg cramps but would not necessarily be related to walking. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 468

A nurse asks a supine client to raise his knee partially. The nurse then places the thumbs on the knee while positioning the fingers deep in the bend of the knee. The nurse is palpating the pulse of which artery? Popliteal Posterior tibial Femoral Dorsalis pedis

Popliteal Explanation: The femoral artery is the major supplier of blood to the legs. Its pulse can be palpated just under the inguinal ligament. This artery travels down the front of the thigh then crosses to the back of the thigh, where it is termed the popliteal artery. The popliteal pulse can be palpated behind the knee. The popliteal artery divides below the knee into anterior and posterior branches. The anterior branch descends down the top of the foot, where it becomes the dorsalis pedis artery. Its pulse can be palpated on the great toe side of the top of the foot. The posterior branch is called the posterior tibial artery. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 480

What pulse is located in the groove between the medial malleolus and the Achilles tendon? Dorsalis pedis Popliteal Femoral Posterior tibial

Posterior tibial Explanation: The posterior tibial pulse is located in the groove between the medial malleolus and the Achilles tendon. The femoral pulse is about halfway between the symphysis pubis and the anterior iliac spine, just below the inguinal ligament. The popliteal pulse is often difficult to locate. It may be felt immediately lateral to the medial tendon. A light touch is important to avoid obliterating the dorsalis pedis pulse. It is normally about halfway up the foot immediately lateral to the extensor tendon of the great toe. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 464

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? Quitting smoking and keeping good control of your blood sugar levels are important. If you develop swelling in your ankles or feet, then you should seek emergency care. It's critical that you come to get screening tests twice annually. I'll show you how to check your pulses at your groin, knees and feet to monitor your risk of PAD.

Quitting smoking and keeping good control of your blood sugar levels are important. Explanation: Smoking cessation and adequate glycemic control should be prioritized when teaching this client. Ankle edema should be assessed and followed up, but would not likely necessitate emergency care. Clients are not normally taught self-assessment of pulses, and quitting smoking and controlling blood glucose are more important than screening tests. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 471

Goals, although not specific for peripheral vascular disease, focus on areas of risk. What are these areas of modifiable risk? Select all that apply. Lack of exercise Ethnicity Family history Overweight Smoking

Smoking Overweight Lack of exercise Explanation: Goals are not specific for peripheral vascular disease but instead focus on areas of risks for such disease, such as smoking, overweight, and lack of regular exercise. Family history and ethnicity are not modifiable risk factors.

The radial pulse is palpated over the lateral flexor surface. False True

True Reference: Chapter 22: Assessing Peripheral Vascular System - Page 464

Which nursing assessment finding supports the diagnosis of chronic arterial insufficiency? Skin temperature of the leg is normal. Skin is cyanotic when the leg is in a dependent position. Leg pulses are normal but difficult to assess because of edema. Ulceration is noted on the great toe of the affected foot.

Ulceration is noted on the great toe of the affected foot. Explanation: Advanced chronic arterial insufficiency would present with possible ulcers involving toes or points of trauma on the feet. The remaining options are supportive of advanced chronic venous insufficiency. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 489

Which area of the arm drains to the epitrochlear nodes? Ulnar surface of the forearm and hand; second, third, and fourth fingers Ulnar surface of the forearm and hand, little and ring fingers, and ulnar middle finger Radial surface of the forearm and hand, thumb and index finger, and radial middle finger Radial surface of the forearm and hand; second, third, and fourth fingers

Ulnar surface of the forearm and hand, little and ring fingers, and ulnar middle finger Explanation: The epitrochlear node receives lymphatic drainage from the ulnar surface of the forearm and hand, little and ring fingers, and ulnar middle finger. More importantly, it is generally a sign of generalized lymphadenopathy as seen in syphilis and HIV infection. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 468-476

Which statement describes the correct technique by a nurse when performing the ankle-brachial pressure index test? Record the last signal that is auscultated as the ankle pressure. Quickly deflate the blood pressure cuff to allow blood to return to the extremity. Inflate the blood pressure cuff 40-50 mm Hg beyond where the last signal was heard. Use a blood pressure cuff that is 20% wider than the diameter of the client's limb.

Use a blood pressure cuff that is 20% wider than the diameter of the client's limb. Explanation: The correct technique involves using a blood pressure cuff that is 20% wider than the diameter of the limb being measured, inflating the cuff to no more than 20-30 mm Hg beyond when the last arterial signal was detected, slowly deflating the cuff so as to not miss the highest pressure. This first signal is the arterial pressure and is the number recorded, not the last sound heard. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 484

During the assessment, the nurse identifies warm thick skin that is reddish-blue. The nurse also notes a painful ulcer at the ankle. The nurse suspects the client may have what? Intermittent claudication Venous insufficiency Hypertrophic changes Arterial insufficiency

Venous insufficiency Explanation: Venous insufficiency is characterized by aching, cramping, pigment changes. If the client has an ulcer, it will be painful. Arterial insufficiency is characterized by decreased pulses, dry, shiny, cold skin. Intermittent claudication is pain brought on by exertion and relieved by rest. Hypertrophic changes include a loss of hair and pallor. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 488

When you enter the room of a hospitalized client, you note that the client is guarding her left leg, which is swollen and reddened. You should identify the signs and symptoms of what complication of hospitalization? Sepsis Fluid imbalance Decreased mobility Venous thromboembolism

Venous thromboembolism Explanation: Edema, pain or achiness, erythema, and warmth in the leg are common signs and symptoms of venous thromboembolism.

The major artery that supplies blood to the arm is the brachial artery. ulnar artery. posterior artery. radial artery.

brachial artery. Explanation: The brachial artery is the major artery that supplies the arm. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 464

The posterior tibial pulse can be palpated at the ankle. great toe. top of the foot. knee.

ankle. Explanation: The posterior tibial pulse can be palpated behind the medial malleolus of the ankle. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 464

After palpating the radial pulse of an adult client, the nurse suspects arterial insufficiency. The nurse should next assess the client's tibial pulse. brachial pulse. femoral pulse. popliteal pulse.

brachial pulse. Explanation: You can also palpate the brachial pulses if you suspect arterial insufficiency. Do this by placing the first three fingertips of each hand at the client's right and left medial antecubital creases. Alternatively, palpate the brachial pulse in the groove between the biceps and triceps. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 474

After palpating the radial pulse of an adult client, the nurse suspects arterial insufficiency. The nurse should next assess the client's tibial pulse. popliteal pulse. brachial pulse. femoral pulse.

brachial pulse. Explanation: You can also palpate the brachial pulses if you suspect arterial insufficiency. Do this by placing the first three fingertips of each hand at the client's right and left medial antecubital creases. Alternatively, palpate the brachial pulse in the groove between the biceps and triceps. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 474

The nurse documents a 2+ radial pulse. What assessment data indicated this result? brisk, expected (normal) pulse absent (unable to palpate) pulse diminished pulse bounding pulse

brisk, expected (normal) pulse Explanation: A +2 pulse is a normal pulse. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 485

The diagnosis of superficial phlebitis increases the client's risk for which vascular disorder? acute lymphangitis deep vein thrombosis compartment syndrome acute cellulitis

deep vein thrombosis Explanation: Superficial phlebitis is an inflammation of a superficial vein that can lead to deep vein thrombosis. Compartment syndrome is a result of pressure building from trauma or bleeding into one of the four major muscle compartments between the knee and ankle. Acute lymphangitis is a bacterial infection from Streptococcus pyogenes or Staphylococcus aureus, spreading up the lymphatic channels from a distal portal of entry. Acute cellulitis is a bacterial infection of the skin and subcutaneous tissues. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 481

The nurse is caring for a client who is employed as a typist and has a family history of peripheral vascular disease. The nurse should instruct the client to reduce her risk factors by drinking large quantities of milk. eating a high-protein diet. getting regular exercise. resting frequently.

getting regular exercise. Explanation: Regular exercise improves peripheral vascular circulation and decreases stress, pulse rate, and blood pressure, decreasing the risk for developing PVD. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 471

The nurse is assessing an older adult. The client states that she feels a constant, sharp pain only when walking. The nurse suspects the client is experiencing what? Deep vein thrombosis Varicose veins Intermittent claudication Pulmonary embolism

he nurse is assessing an older adult. The client states that she feels a constant, sharp pain only when walking. The nurse suspects the client is experiencing what? You Selected: Intermittent claudication Correct response: Intermittent claudication Explanation: Pain brought on by exertion and relieved by rest is called intermittent claudication. Varicose veins are due to incompetent valves. Signs of a pulmonary embolus include acute dyspnea, chest pain, tachycardia, diaphoresis, a anxiety. Deep vein thrombosis symptoms include pain, edema, and warmth of an extremity. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 468

A client visits the clinic and tells the nurse that she had a mastectomy 2 years ago. The nurse should assess the client for lymphedema. poor peripheral pulses. bruits over the radial artery. Raynaud disease.

lymphedema. Explanation: Lymphedema results from blocked lymphatic circulation, which may be caused by breast surgery. It usually affects one extremity, causing induration and nonpitting edema. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 474

The nurse is preparing to use a Doppler ultrasound probe to detect blood flow in the femoral artery of an adult client. The nurse should apply gel used for ECG to the client's skin. apply K-Y jelly to the client's skin. place the tip of the probe in a 30-degree angle to the artery. place the client in a supine position with the head flat.

pply K-Y jelly to the client's skin. Explanation: When assessing peripheral circulation with a Doppler ultrasound device, inform the client that the assessment is painless and noninvasive. Then apply a fingertip-sized mound of lukewarm gel over the blood vessel to be assessed. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 473

The nurse is assessing a client's lymphatic system. For which enlarged node should the nurse suspect that the client has a blockage within the right lymphatic duct? superficial inguinal node superficial popliteal node right cervical node lumbar node

right cervical node Explanation: The right cervical node drains into the right lymphatic duct. The lumbar, superficial inguinal, and superficial popliteal nodes drain into the thoracic duct. Reference: Chapter 22: Assessing Peripheral Vascular System - Page 467