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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Listening to speech primarily assesses cranial nerves related to speech and articulation, not cranial nerve II.
B. Identifying scented aromas assesses the olfactory nerve.
C. Clenching teeth primarily assess cranial nerve V (trigeminal nerve).
D. Cranial nerve II is the optic nerve responsible for vision. Testing visual acuity using a Snellen chart assesses this nerve's function.
Correct Answer is D
Explanation
A. A peritoneal friction rub is a grating sound caused by inflamed surfaces of the peritoneum rubbing together.
B. Borborygmi refers to loud, gurgling bowel sounds often heard with increased intestinal motility.
C. Hypoactive bowel sounds are abnormally decreased or absent bowel sounds.
D. Borborygmi describes the normal sounds made by the movement of gas and fluid in the intestines.
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