The nurse has completed a peripheral vascular assessment on a client. Which of the following would the nurse document as expected findings?

Capillary refill <5 seconds.

Radial pulses 2+ with regular rate and rhythm bilaterally.

Feet pale and cool to the touch.

Right ankle 1+ edema with no perceptible swelling of the leg.

Answer and Explanation

The Correct Answer is B

A.   A capillary refill of less than 5 seconds is considered normal.
B.   Radial pulses 2+ with regular rate and rhythm bilaterally indicate good peripheral circulation.
C.   Feet that are pale and cool to the touch could indicate decreased perfusion or vascular compromise.
D.   Right ankle 1+ edema may suggest some fluid retention but no perceptible swelling of the leg indicates relatively normal findings in that area.

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Correct Answer is C

Explanation

A. The sigmoid is a part of the large intestine located in the left lower quadrant, so tenderness in the right lower quadrant is unlikely to be related to the sigmoid.
B. The liver is situated higher in the abdomen, typically more towards the right upper quadrant, and its tenderness wouldn't manifest in the right lower quadrant.
C. Tenderness in the right lower quadrant is a classic sign of appendicitis, suggesting inflammation of the appendix.
D. The gallbladder is positioned closer to the liver, in the right upper quadrant, and wouldn't typically cause tenderness in the right lower quadrant.

A. Observing for facial symmetry B. Checking the pupillary response to light C. Testing visual acuity D. Eliciting the gag reflex

Correct Answer is B

Explanation

A. Observing for facial symmetry is more related to Cranial Nerve VII (Facial nerve) function.
B. Cranial Nerve III (Oculomotor nerve) controls the pupillary response to light, as well as eye movement.
C. Testing visual acuity is associated with Cranial Nerve II (Optic nerve).
D. Eliciting the gag reflex involves the Cranial Nerve IX (Glossopharyngeal nerve) and Cranial Nerve X (Vagus nerve).

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The nurse has completed a peripheral vascular assessment on a client. Which of the following would the nurse document as expected findings?

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Naxlex Comprehensive Predictor Exams

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