PrepU Chapter 18 - Peripheral Vascular with Lymphatics

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?

1.1

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?

4+

A nurse palpates the presence of an enlarged inguinal lymph node. Which area of the client's body should the nurse thoroughly examine to assess for the source of this finding?

Abdomen, noting any organ enlargement or tenderness

The physician is preparing to insert a radial arterial line. What test must be performed prior to insertion?

Allen test

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?

Ankle-brachial index (ABI)

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. What would the nurse suspect?

Arterial insufficiency

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?

Arterial insufficiency

The client complains of pain and numbness in his left lower leg. The nurse identifies on assessment that the left leg is cool and gray in color. The nurse suspects what?

Arterial occlusion

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?

Assess adequacy of blood flow using a Doppler device.

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 the client to walk as soon and as often as possible.

Assessment of a client's lower extremities reveals unilateral edema of the right foot and ankle. What would the nurse do next?

Compare measurements of both extremities.

The nurse is caring for a client with venous ulcers on both legs. The client is complaining of pain. What is the nurse's best action?

Elevate the legs on pillows.

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?

Ensure that the client's hand is not opened in exaggerated extension

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?

Firmly compress the lower portion of the varicose vein

What is the Virchow triad? (Mark all that apply.)

Hypercoagulability Vessel wall damage Venous stasis

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

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?

Intermittent claudication

A nurse performs the Trendelenburg test for a client with varicose veins. What care should the nurse take when performing this test?

Legs should be elevated for 15 seconds.

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?

Lightly palpate the client's leg veins for tenderness

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?

Lower arm and hand for erythema and swelling

A client is admitted with leg ulcers to the health care facility. During the collection of objective data, which assessment finding should indicate to the nurse that the client's leg ulcers are due to arterial insufficiency?

Pallor of foot occur with elevation

A nurse is unable to palpate a client's radial and ulnar pulses. What is the most appropriate nursing action?

Palpate the brachial pulse.

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?

Peripheral vascular problems

A nurse experiences difficulty in palpating the popliteal pulses in a client during assessment of the peripheral vascular system. What should the nurse do to assist in locating this pulse on a client?

Place the client in the prone position.

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?

The nurse should implement interventions to address severe arterial insufficiency.

On inspection of a client's legs, the nurse has found varicose veins. Which test should the nurse next perform to determine the competence of the saphenous vein valves?

Trendelenburg test

The radial pulse is palpated over the lateral flexor surface.

True

A nurse is palpating a client's epitrochlear nodes. The nurse is palpating which area?

Upper arm

The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following?

Venous insufficiency

A client has been diagnosed with venous insufficiency. Which of the following findings should the nurse expect on interviewing this client?

Warm skin and brown pigmentation around the ankles

What is a long-term complication of peripheral vascular disease?

amputation

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?

an oral contraceptive

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

arterial insufficiency

Which alteration in the pattern of the cardiac pulse should a nurse expect to find on examination of a client who has one normal beat followed by a premature contraction in conjunction with premature ventricular contractions?

bigeminal pulse

The nurse is planning to perform the Trendelenburg test on an adult client. The nurse should explain to the client that this test is used to determine the

competence of the saphenous vein valves.

A nurse recognizes which finding as an indication of an ulcer due to arterial insufficiency?

deep ulcers that often involve joint space

The diagnosis of superficial phlebitis increases the client's risk for which vascular disorder?

deep vein thrombosis (DVT)

During assessment, the nurse notes the client has a decreased pain sensation in his low extremities. The nurse should ask the client about a history of what disease?

diabetes

A client presents with lymphedema in one arm, with nonpitting edema. Which of the following should the nurse assess for, based on this finding?

history of breast surgery

The popliteal artery can be palpated at the

knee.

While assessing the inguinal lymph nodes in an older adult client, the nurse detects that the lymph nodes are approximately 3 cm in diameter, nontender, and fixed. The nurse should refer the client to a physician because these findings are generally associated with

malignancy

A nurse assists the client to perform the position change test for arterial insufficiency. While the client is dangling the legs, the nurse observes a return of color to the feet in 8 seconds. How should the nurse document the finding for this test?

normal

A 42-year-old woman reveals an intake of medications. Which medication if reported by the client would alert the nurse to the need to assess the client for thrombophlebitis?

oral contraceptive

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?

right cervical node

The nurse is preparing discharge teaching for a patient diagnosed with a lymphatic disorder. What is one of the main teaching points the nurse should include?

to avoid sitting for long periods

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?

venous insufficiency

The nurse notes that a client has a painful ulcerative lesion near the medial malleolus with accompanying hyperpigmentation. Which of the following etiologies is most likely?

venous insufficiency