When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. Next, the nurse should;
Ask the patient if he or she has experienced any unusual cramping or tingling in the arm.
Refer the individual for further evaluation.
Check for the presence of claudication.
Consider this finding as normal, and proceed with the peripheral vascular evaluation.
The Correct Answer is D
A. Asking about cramping or tingling is unnecessary without other signs of compromised circulation.
B. Referral is not needed if perfusion is adequate.
C. Checking for claudication relates to arterial insufficiency, not absence of ulnar pulse.
D. Proceeding with the evaluation is appropriate if perfusion is adequate, as indicated by normal capillary refill and warm skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Smallest speculum: The smallest speculum may not provide the best view of the ear canal and tympanic membrane, especially in adults. The correct size should be chosen for adequate visualization.
B. Releasing the traction: Traction should be maintained to stabilize the ear and allow a better view of the ear canal.
C. Tilting the person's head forward: This is not the ideal positioning for the ear examination. The head should be tilted slightly away to straighten the ear canal.
D. Pulling the pinna up and back: This helps straighten the ear canal, especially in adults, providing better visualization during the otoscopic examination.
Correct Answer is B
Explanation
A. Ptosis: Drooping of the upper eyelid, often caused by nerve or muscle dysfunction.
B. Ectropion: This condition results from age-related weakening of eyelid muscles or facial nerve palsy, causing the lower eyelid to turn outward, exposing the conjunctiva.
C. Exophthalmos: Protrusion of the eyeball, commonly seen in conditions like Graves' disease.
D. Entropion: Inward rolling of the eyelid, leading to eyelashes rubbing against the eye.
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