The student nurse is preparing to perform an assessment of the client's peripheral vascular system. The experienced nurse asks the student nurse questions to ensure the student nurse has prepared adequately
Which of the following statements by the student nurse indicate that further education is required? Standard Text: Select all that apply. 1. "I need to take a blood pressure only in the client's right arm.".
2. "The best way to assess the carotid pulses is palpate one side and then the other.".
3. "It will be easier to assess the client's carotid pulses if the client is obese.".
4. I should inspect the arms to ensure that they are close to the same size.".
5. "I should look at the extremities to ensure that hair distribution is normal and symmetrical. The skin should be clean and free of any lesions.".
1,3
Rationale 1: "I need to take a blood pressure only in the client's right arm.". A thorough peripheral vascular assessment includes blood pressure measurements taken in both arms and both legs.
Rationale 2: "The best way to assess the carotid pulses is palpate one side and then the other.". The carotid pulses should not be palpated at the same time because it may cause the client to faint or pass out due to lack of blood flow to the brain.
Rationale 3: "It will be easier to assess the client's carotid pulses if the client is obese.". It is much easier to assess the client's carotid pulses when the client has a long, thin neck.
Rationale 4: "I should inspect the arms to ensure that they are close to the same size.". The arms should be compared to each other to ensure that there is not a lymphatic problem that has developed that would result in edema.
Rationale 5: "I should look at the extremities to ensure that hair distribution is normal and symmetrical. The skin should be clean and free of any lesions.". The skin on the extremities should be clean, dry, and intact. The client's pattern of hair distribution should be evaluated to determine if there is adequate arterial circulation.
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