Which of the following should the nurse perform to assess the arterial function of the lower extremities?
Assess for pretibial edema
Palpate pedal pulses bilaterally
Allen test
Homan sign
The Correct Answer is B
A. Pretibial edema: Edema is more indicative of venous function, not arterial function.
B. Palpate pedal pulses bilaterally: Palpation of the pedal pulses is essential to assess arterial circulation in the lower extremities.
C. Allen test: This assesses arterial blood flow to the hand, not the lower extremities.
D. Homan sign: Homan sign is used (though controversial) to assess for deep vein thrombosis (DVT), which is related to venous, not arterial, function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Shine a light across the pupil from the side: To assess the pupillary light reflex, the nurse should shine a light across the pupil from the side and observe for both direct and consensual constriction (the constriction of both pupils when one is exposed to light).
B. Follow the penlight: This tests for accommodation (focusing on near objects) rather than the pupillary light reflex.
C. Shine a penlight directly in front: This method doesn’t assess both direct and consensual constriction properly.
D. Focus on a distant object: This assesses accommodation, not the pupillary light reflex.
Correct Answer is B
Explanation
A. Capillary refill time greater than 2 seconds is abnormal and requires further assessment.
B. A capillary refill time of 5 seconds indicates delayed peripheral perfusion and warrants further investigation.
C. While frostbite can cause delayed refill, it is less likely than vascular insufficiency in this scenario.
D. Delayed capillary refill is more often associated with arterial, not venous, insufficiency.
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