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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;

A.

Ask the patient if he or she has experienced any unusual cramping or tingling in the arm.

B.

Refer the individual for further evaluation.

C.

Check for the presence of claudication.

D.

Consider this finding as normal, and proceed with the peripheral vascular evaluation.

Answer and Explanation

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.


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"}}

Explanation

Each category must have at least 1 response option selected

Finding

Normal

Abnormal

Tympany to percussion over the intestines

✅

Loose, watery stool

✅

Suprapubic tenderness

✅

A non-palpable spleen

✅

Aortic pulsation in the epigastric area

✅

Decreased bowel sounds

✅

Rationale:

Tympany to percussion over the intestines (Normal):

Tympany is expected due to the presence of gas in the intestines.

Loose, watery stool (Abnormal):

This is indicative of diarrhea, which may point to gastrointestinal upset or infection.

Suprapubic tenderness (Abnormal):

Tenderness in this area may indicate bladder infection, inflammation, or pelvic issues.

A non-palpable spleen (Normal):

The spleen is generally not palpable in healthy individuals unless it is enlarged (splenomegaly).

Aortic pulsation in the epigastric area (Normal):

Mild pulsations may be felt in thin or normal-weight individuals. However, a widened or strong pulsation could suggest an abdominal aortic aneurysm.

Decreased bowel sounds (Abnormal):

Hypoactive or absent bowel sounds may indicate decreased intestinal motility, such as in ileus or peritonitis.

Correct Answer is C

Explanation

A. Atrophy of calf veins: Vein atrophy is not a normal aging process, although venous insufficiency is common due to other causes.

B. Narrowing of the inferior vena cava: This is not a typical age-related change.

C. Peripheral blood vessels growing more rigid: Arteriosclerosis (hardening of the arteries) is common with aging and leads to increased systolic blood pressure.

D. Hormonal changes causing vasodilation: Aging tends to cause vascular rigidity, not vasodilation, and is more likely to lead to hypertension.

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