Peripheral Vascular and Lymphatics

Question 1

The nurse prepares to complete a history and physical assessment. Ms. Empanio asks the nurse to call her Gloria.
1.
The nurse reviews Gloria’s initial complaint that her feet feel numb. What assessment should the nurse perform first?

Locate the inguinal lymph nodes.

Measure toenail capillary refill.

Compare calf circumferences.

Palpate the dorsalis pedis pulses

Answer 1

Locate the inguinal lymph nodes.
Palpation of lymph nodes should be included in the physical assessment, but is not the priority assessment at this time.
Measure toenail capillary refill.
Length of capillary refill provides useful information about arterial circulation, but is not the best assessment to complete at this time.
Compare calf circumferences.
Calf circumference provides useful data related to possible deep vein thrombosis, but is not the most important assessment at this time.
Palpate the dorsalis pedis pulses. Correct
Because the client has complained of numbness, it is important to assess for the presence and strength of the pedal pulses, a measure of the arterial circulation to the feet. The acute absence of arterial circulation would require immediate intervention.

Question 2

The nurse palpates the dorsalis pedis pulses bilaterally and determines that both pulses are weak and thready.
2.
What additional assessment finding will validate this finding?
Pale, cool skin.
Flushed, moist skin.
Inflamed, hot skin.
Dry, inelastic skin.

Answer 2

Pale, cool skin. Correct
Weak, thready pulses indicate diminished arterial circulation. Pale, cool skin is also likely to be present when arterial circulation is diminished, validating the finding of weak, thready pulses.
Flushed, moist skin.
This finding is not consistent with weak, thready pulses.
Inflamed, hot skin.
This finding is not consistent with weak, thready pulses.
Dry, inelastic skin.
This finding may be present, but does not validate the presence of weak, thready pulses.

Question 3

Gloria’s feet are pale and cool to the touch, consistent with the weak, thready pedal pulses palpated by the nurse.

The nurse uses a Doppler ultrasound stethoscope to confirm the presence of the dorsalis pedis pulses. After applying gel to the transducer and placing the transducer over the middle of the dorsal surface of the foot, the nurse hears a regular swooshing sound.

What action should the nurse take?
Notify the healthcare provider immediately of the lack of a pulse.
Move the end of the transducer closer to the toes and listen again.
Remove the excess gel, apply pressure more gently, and try again.
Document the presence of the pulse heard by Doppler ultrasound.

Answer 3

Notify the healthcare provider immediately of the lack of a pulse.
This action is not indicated.
Move the end of the transducer closer to the toes and listen again.
It is not necessary to take this action.
Remove the excess gel, apply pressure more gently, and try again.
It is not necessary to take this action.
Document the presence of the pulse heard by Doppler ultrasound. Correct
A regular swooshing sound indicates that a pulse is heard with the Doppler ultrasound stethoscope. This finding should be documented.

After ensuring that arterial circulation is present, the nurse next assesses Gloria’s wound.

Question 4

The wound Gloria mentioned is located on the plantar surface of her right foot, on the ball of the foot.
The nurse observes that the wound bed is red and the tissue immediately surrounding the wound is inflamed. The nurse plans to document the stage of the wound.

What additional action should the nurse take to correctly stage the wound?
Determine the depth of the wound and underlying tissue damage.
Measure the width of the wound from front-to-back and side-to side.
Note the amount, color, and character of the wound drainage.
Observe the tissue to determine the phase of wound healing.

Answer 4

Determine the depth of the wound and underlying tissue damage. Correct
Pressure ulcers are staged based on the depth of tissue damage to the dermis and underlying tissues, which may include underlying tendons, joint capsules, bones, and muscles.
Measure the width of the wound from front-to-back and side-to side.
This assessment provides useful information, but is not used in staging a pressure ulcer.
Note the amount, color, and character of the wound drainage.
This assessment provides useful information, but is not used in staging a pressure ulcer.
Observe the tissue to determine the phase of wound healing.
This assessment provides useful information, but is not used in staging a pressure ulcer.

Question 5

The nurse determines that Gloria’s wound is a stage II pressure ulcer.

The nurse notes that the wound is round and 0.5 cm in diameter. To assess for the presence of any undermining tracts, what action should the nurse implement?

a) Note the amount and appearance of any drainage.
b) Gently irrigate the wound with sterile saline.
c) Insert a sterile, cotton-tipped applicator.
d) Use sterile forceps to apply sterile packing.

Answer 5

Note the amount and appearance of any drainage.
The amount and appearance of any drainage does not provide data about the depth of the wound and any undermining tracts.
Gently irrigate the wound with sterile saline.
Wound irrigation does not provide an effective measurement of the depth of the wound and any undermining tracts.
Insert a sterile, cotton-tipped applicator. Correct
A sterile, cotton-tipped applicator can be gently inserted to measure the depth of the wound and any undermining tracts.
Use sterile forceps to apply sterile packing.
The application of packing does not provide an effective measurement of the depth of the wound and any undermining tracts.

Question 6

While the nurse assesses the wound, Gloria mentions that she found a stone in her shoe, and thinks that the stone caused the sore on her foot. She states she never felt the stone in her shoe. The nurse questions Gloria further about the onset of loss of sensation in her feet, and proceeds with the client interview.

After completing the focused assessment of Gloria’s pedal pulses, the wound on the bottom of her foot, and Gloria’s subjective report of numbness, the nurse begins to obtain the client’s history, focusing on data related to her peripheral vascular system.
6.
To learn about any history of intermittent claudication, what question should the nurse ask?

When you first stand up, do you feel dizzy or light-headed?
Can you feel your pulse pounding after vigorous activity?
Have you experienced any leg cramping or pain in your legs?
Do you have an urge to move your legs a lot during the night?

Answer 6

When you first stand up, do you feel dizzy or light-headed?
This question will elicit information about possible orthostatic hypotension.
Can you feel your pulse pounding after vigorous activity?
This question will elicit information about cardiac function.
Have you experienced any leg cramping or pain in your legs? Correct
Claudication is cramp-like calf pain, associated with diminished blood supply to the leg muscles. When this pain occurs only at specific times, such as during activities, it is referred to as intermittent claudication.
Do you have an urge to move your legs a lot during the night?
This question will elicit information about possible restless leg syndrome.

Question 7

The client reports she often experiences leg cramps, usually after walking around the park.

What follow-up question by the nurse provides the best information about the client’s claudication distance?
When did you first notice you were having leg cramps?
How long have you been walking this same distance?
On a 10-point scale, how would you rank your pain?
How far do you walk before the leg cramps begin?

Answer 7

When did you first notice you were having leg cramps?
This question will not provide information about claudication distance.
How long have you been walking this same distance?
This question will not provide information about claudication distance.
On a 10-point scale, how would you rank your pain?
This question will not provide information about claudication distance.
How far do you walk before the leg cramps begin? Correct
Claudication distance refers to the distance, such as blocks walked, or stairs climbed, that produces pain.

Question 8

The nurse has already observed that both of Gloria’s feet are cool and pale. What question should the nurse ask Gloria to obtain additional supporting data?
Do your toes or toenails ever look blue?
After a bump, do you bruise easily?
Are any of your veins bulging or crooked?
Have you ever had a blood clot?

Answer 8

Do your toes or toenails ever look blue? Correct
Cool skin temperature and pallor are signs of diminished arterial circulation. Cyanosis, a bluish color, of the tips of the toes or nail beds, is also an indicator of decreased arterial circulation.
After a bump, do you bruise easily?
Cool skin temperature and pallor are signs of diminished arterial circulation. Bruising easily may be an indicator of a clotting problem, but is not a sign of diminished arterial circulation.
Are any of your veins bulging or crooked?
Bulging or crooked veins are typical of varicose veins, but are not a sign of diminished arterial circulation.
Have you ever had a blood clot?
A history of a blood clot might cause venous insufficiency, contributing to diminished circulation unilaterally, rather than bilaterally.

Question 9

The nurse begins the assessment at the client’s inguinal area, assessing the femoral artery and the inguinal lymph nodes.
The nurse palpates the femoral artery and notes that it is weak. The nurse decides to assess for the presence of a bruit.

What action should the nurse take?

Feel the inguinal area with the back of the hand.

Firmly compress the artery with the fingertips.

Position a stethoscope over the artery

Observe the site for bulges or swelling.

Answer 9

Feel the inguinal area with the back of the hand.
The back of the hand is useful in assessing skin temperature but is not useful in assessing for a bruit.
Firmly compress the artery with the fingertips.
This action will not enable the nurse to assess for a bruit.
Position a stethoscope over the artery. Correct
A bruit is a swooshing sound heard when blood flow through an artery is turbulent. It is heard by placing a stethoscope over the artery.
Observe the site for bulges or swelling.
This action will not enable the nurse to assess for a bruit.

Question 10

.
After assessing the femoral artery, the nurse palpates the inguinal lymph nodes. What technique should be used?

Lightly press the palmar surface of one hand over the inguinal area.

Move the finger pads over the area using a gentle circular motion.

Firmly compress the area until blanching occurs and then release.

Gently press downward with the fingertips until the node is felt.

Answer 10

Lightly press the palmar surface of one hand over the inguinal area.
This is not the most effective technique to palpate the lymph nodes.
Move the finger pads over the area using a gentle circular motion. Correct
This technique allows effective palpation of the lymph nodes.
Firmly compress the area until blanching occurs and then release.
This technique is not used to palpate the lymph nodes.
Gently press downward with the fingertips until the node is felt.
This is not the most effective technique to palpate the lymph nodes.

Question 11

During the health history, Gloria reported that her feet and ankles swell occasionally. To assess for edema, what action the nurse take first?
Ask the client to lie down and elevate her feet and legs.
Observe and compare the client’s lower extremities.
Gently compress the tissue on the top of her feet.
Ask the client to gently dorsiflex each of her feet.
12.

Answer 11

Observe and compare the client’s lower extremities.
The nurse should first assess for edema by observing the client’s legs for any obvious swelling, and comparing the two extremities for differences in size.

Question 12

Although there is no visible swelling, Gloria’s legs are large, so the nurse gently depresses the tissue over the tibia for one second, noting that the tissue bounces back immediately. What action should the nurse take next?
Document the presence of non-pitting edema.
Note that there is currently no edema present.
Ask the client to elevate her legs and repeat.
Compress the tissue more firmly for 5 seconds.

Answer 12

Compress the tissue more firmly for 5 seconds. Correct
To effectively assess for pitting edema, the nurse should firmly depress the tissue for 5 seconds, release, and measure any resultant indentation

Question 13

The nurse asks Gloria to stand and assesses for the presence of varicose veins. A large dilated, torturous vein is observed, so the nurse checks for valve competence by placing one hand at the lower end of the vein, and then compressing the vein with the other hand 20 cm higher

What should the nurse do next?
Note any change in skin color distal to the compressed vein.

Palpate for a wave transmission with the distal hand.

Observe for any swelling along the length of the vein.

Ask the client if she is experiencing any pain or discomfort.

Answer 13

Palpate for a wave transmission with the distal hand. Correct
Competent valves will prevent a wave

Question 14

The nurse’s assessment reveals that the valves are competent and the nurse continues the assessment.
While Gloria is standing, the nurse notes the absence of any dependent rubor.

What action should the nurse take in response to this finding?

Document this finding on the physical assessment form

Immediately help the client sit down and elevate her legs.

Lightly palpate the calves for warmth or tenderness.

Assess for range of motion in the lower legs and feet.

Answer 14

Document this finding on the physical assessment form. Correct

Question 15

The nurse next plans to determine the client’s ankle brachial index.

What equipment should the nurse obtain prior to completing this measurement?

Measuring tape.

Blood pressure cuff

Pulse oximeter.

Tourniquet.

Answer 15

Blood pressure cuff. Correct
A blood pressure cuff along with a Doppler probe is used to obtain the systolic blood pressure in the lower extremity. To calculate the ankle brachial index (ABI), this value is compared with the systolic blood pressure in the upper extremity

Question 16

The clinic supervisor enters Gloria’s room, and the nurse gives the supervisor a brief report, based on the assessment completed up to this point.
16.
It is most important to report which finding to the supervisor?
Lack of dependent rubor.
Location of varicose veins.
Stage 2 pressure ulcer.
Ankle brachial index of .94.

Answer 16

Stage 2 pressure ulcer. Correct
A stage 2 pressure ulcer in a client with diminished sensation and circulation requires intervention and takes precedence over the other findings listed here.

Question 17

When reporting to the supervisor, the nurse tells the supervisor that the client's pressure sore developed because she had a stone in her shoe that she couldn't feel. How should the nurse summarize this initial report by the client?
  Foot paralysis bilaterally.
  Discomfort in both feet.
  Numbing pain in her feet.
  Bilateral parasthesia in the feet.

Answer 17

Bilateral parasthesia in the feet. Correct
Parasthesia refers to abnormal sensation, such as numbness or tingling, so this is the best terminology to describe the client’s report of numbness and lack of feeling in her feet.

Question 18

In selecting a site to draw the blood sample, the nurse observes that Gloria’s left forearm is swollen. Gloria reports that she cut her left forearm a week earlier, and reminds the nurse she had left breast surgery 2 years previously. The nurse draws the blood samples from Gloria’s right arm and then proceeds to assess Gloria’s lymph nodes.

To palpate the epitrochlear node, the nurse palpates the area above and behind the medial condyle of the humerus, but is unable to palpate the node.

What action should the nurse take next?
Palpate the area below the medial condyle.
Ask the client to slowly flex her elbow.
Document that the node is not palpable.
Apply pressure over the antecubital fossa.

Answer 18

Document that the node is not palpable. Correct
The epitrochlear lymph node is located in the groove between the biceps and triceps muscles, above the medial epicondyle of the humerus and is not palpable normally.

Question 19

The nurse next palpates the axillary nodes. Using the pads of the fingers, the nurse moves over the node area in a circular motion. Two nodes are palpable and are easily movable.

What action(s) should the nurse take in response to this finding? (Select all that apply.)
Document the assessment as within normal limits in the assessment record.
Note the amount of pressure needed to occlude the nodes and prevent movement.
Apply pressure more firmly until all the nodes in the area can be palpated.
Assess the nodes further for consistency, and any palpable matting.
Ask Gloria if any there is any tenderness upon palpation of the nodes.

Answer 19

Assess the nodes further for consistency, and any palpable matting. Correct
If lymph nodes are palpable, the nurse should assess for mobility, size, shape, consistency, and whether the nodes are discrete or matted. These findings should then be documented in the assessment record.

Ask Gloria if any there is any tenderness upon palpation of the nodes. Correct
If lymph nodes are palpable, the nurse should assess for tenderness. This finding should then be documented in the assessment record.

Question 20

The nurse continues assessment of Gloria’s upper extremities, palpating the brachial and radial pulses.
20.
To assess capillary refill of the fingernails, the nurse begins with what action?
Observe the nailbed angle.
Depress the client’s nailbed.
Place the fingertips in a dependent position.
Count the radial pulse for 30 seconds.

Answer 20

Depress the client’s nailbed. Correct
To assess capillary refill, the nurse first compresses the nailbed for 3 seconds. This results in blanching of the nailbed. The nurse then measures the amount of time necessary for return of normal color of the nailbeds – the capillary refill time

Question 21

Gloria’s capillary refill is less than 2 seconds, within normal limits.

To complete the assessment of Gloria’s arterial circulation, the nurse performs a modified Allen test. Which action(s) should the nurse take? (Select all that apply.)

Instruct Gloria to make a fist several times for about 30 seconds

Place the hand in a dependent position.

Obliterate the ulnar and radial pulses.

Instruct Gloria to flex all of her fingers.
Document the results as positive if the hand remains blanched 7-10 seconds after releasing ulnar pressure.

Answer 21

Instruct Gloria to make a fist several times for about 30 seconds. Correct
Making a fist several times causes the hand to blanch during the Modified Allen’s test

Obliterate the ulnar and radial pulses. Correct
The ulnar and radial arteries are obliterated by holding pressure for a few seconds until pallor in the hand occurs.

Document the results as positive if the hand remains blanched 7-10 seconds after releasing ulnar pressure. Correct
A blanched hand or pallor in the fingernails 7-10 seconds after releasing ulnar pressure indicates a positive finding, or impairment to the ulnar artery.

Question 22

Gloria returns to the clinic in 1 week, reporting that her arm seems to be more swollen and inflamed.

To validate this subjective report, the nurse assesses for edema in her arm, noting that 2+ pitting edema is present. During her previous visit, the edema in her arm was recorded as 1+.

22.
What action should the nurse implement?
Reassure Gloria that the swelling has decreased slightly.
Confirm that Gloria’s arm is more swollen than previously.
Document that the swelling has doubled since the last assessment.
Note that the indentation is half as deep as the previous assessment.

Answer 22

Confirm that Gloria’s arm is more swollen than previously. Correct
1+ pitting edema indicates mild pitting, or pitting of 2 mm. 2+ pitting edema indicates moderate edema, or pitting of 4 mm. This finding reflects that Gloria’s arm is more swollen than during the previous assessment.

Question 23

During her initial clinic visit, Gloria’s radial pulse volumes were recorded as 3+ bilaterally. Assessment by the nurse finds that the left radial pulse volume is now 1+, and the right radial pulse volume is 3+.
23.
What additional assessment is most important for the nurse to implement?
Observe the appearance of the left hand.
Palpate the rate of the ulnar pulses bilaterally.
Measure the fingernail capillary refill of the right hand.
Compare hand grip strength bilaterally.

Answer 23

Observe the appearance of the left hand. Correct
A 1+ pulse volume indicates diminished circulation, so further assessment of the left hand is a priority. The nurse should assess the color, warmth, and capillary refill.