The nurse assesses peripheral perfusion. Which does the nurse find in a client with arterial insufficiency?
1. Edema
2. Warm skin
3. Palpable pulses
4. Pain with exercise
4
4. The client with arterial insufficiency usually reports pain with exercise because the arteries to the lower extremities are insufficient to meet tissue oxygen demands; the tissue reverts to anaerobic metabolism with increased accumulation of carbon dioxide and lactic acid, precipitating pain in the tissues. The pain often improves with rest and dependent positioning.
1. Edema is consistent with venous insufficiency.
2 and 3. Warm skin and palpable pulses are consistent with adequate arterial perfu-sion of tissues.
You might also like to view...
Jonathan is a patient diagnosed with Buerger's disease. Instruction for him would include information on
A) anti-inflammatory medications. B) protecting the extremities from coldness. C) quitting smoking. D) anticoagulant therapy.
The nurse is interviewing a client who is 36 weeks pregnant. Which client statement would require immediate intervention by the nurse?
1. "I have to get up during the night to void." 2. "I have not felt the baby move today." 3. "I am leaking a yellowish fluid from my breasts." 4. "I have been taking Tylenol (acetaminophen) for my backaches."
A child has been having an asthma attack for the last 8 hours. Because of the child's inability to exhale effectively, the nurse assesses for respiratory __________
ANS:
The infection control officer recognizes the need for more instruction on surgical asepsis after observing a nurse:
a. facing the sterile field. b. placing a sterile dressing on a sterile field. c. touching the edges of the sterile field with sterile gloves. d. keeping gloved hands above the waist.