A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene?

a. Assessing blood pressure in both upper extremities
b. Auscultating the carotid arteries for any bruits
c. Classifying capillary refill of 4 seconds as normal
d. Palpating both carotid arteries at the same time


ANS: D
The student should not compress both carotid arteries at the same time to avoid brain ischemia. Blood pressure should be taken and compared in both arms. Prolonged capillary refill is considered to be greater than 5 seconds in an older adult, so classifying refill of 4 seconds as normal would not require intervention. Bruits should be auscultated.

Nursing

You might also like to view...

A patient is in the admission department prior to outpatient surgery, and she states that she is exceptionally nervous. Which of the following actions increases this patient's stress-related release of cortisol?

A) Negative feedback mechanism B) Stimulation of the hypothalamus C) Release of epinephrine and norepinephrine D) Atrophy of the adrenal cortex

Nursing

A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection?

a. Appropriate hand hygiene before giving care b. Assessing the client's temperature every 4 hours c. Clean technique when changing dressings d. Monitoring the client's daily white blood cell count

Nursing

A positive Homans' sign is present when the patient complains of pain in the

a. ankle upon dorsiflexion of the foot. c. calf upon flexion of the knee. b. calf upon dorsiflexion of the foot. d. thigh upon elevation of the leg.

Nursing

A 20-year-old patient with a permanent colostomy asks whether she will be able to become pregnant. What is the most informative response by the nurse?

a. "No. The colostomy weakened the pelvic floor to the point that it will not support a pregnancy." b. "Yes. Pregnancy may be accomplished with artificial insemination because the fallopian tubes are usually damaged by a colostomy." c. "No. The abdominal pressure exerted by a pregnancy will cause the prolapse of the stoma." d. "Yes. The colostomy will not interfere with pregnancy or delivery."

Nursing