C HAPTER 12: T HE P ERIPHERAL V ASCULAR
S YSTEM
MULTIPLE CHOICE
1. The nurse is performing an assessment on an adult. The adults vital signs
are normal, and capillary refill time is 5 seconds. What should the nurse
do next?
a. Ask the patient about a history of frostbite.
b. Suspect that the patient has venous insufficiency.
c. Consider this a delayed capillary refill time, and investigate further.
d. Consider this a normal capillary refill time that requires no further
assessment.
ANS: C
Normal capillary refill time is less than 1 to 2 seconds. The following
conditions can skew the findings: a cool room, decreased body
temperature, cigarette smoking, peripheral ede ma, and anemia.
DIF: Cognitive Level: Anal yzing (Anal ysis) REF: p. 516
MSC: Client Needs: Health Promotion and Maintenance
2. When assessing a patient, the nurse notes that the left femoral pulse as
diminished, 1+/4+. What should the nurse do next?
a. Document the finding.
b. Auscultate the site for a bruit.
, c. Check for calf pain.
d. Check capillary refill in the toes.
ANS: B
If a pulse is weak or diminished at the femoral site, then the nurse
should auscultate for a bruit. The presence of a bruit, or turbulent
blood flow, indicates partial occlusion. The other responses are not
correct.
DIF: Cognitive Level: Anal yzing (Anal ysis) REF: p. 521
MSC: Client Needs: Safe and Effective Care Environment:
Management of Care
3. When performing a peripheral vascular asses sment on a patient, the nurse
is unable to palpate the ulnar pulses. The patients skin is warm and
capillary refill time is normal. Next, the nurse should:
a. Check for the presence of claudication.
b. Refer the individual for further evaluation.
c. Consider this finding as normal, and proceed with the peripheral
vascular evaluation.
d. Ask the patient if he or she has experienced any unusual cramping
or tingling in the arm.
ANS: C
Palpating the ulnar pulses is not usuall y necessary. The ulnar pulses
are not often palpable in the normal person. The other responses are
not correct.
, DIF: Cognitive Level: Anal yzing (Anal ysis) REF: p. 517
MSC: Client Needs: Safe and Effective Care Environment:
Management of Care
4. The nurse is assessing the pulses of a patient who has been admitted for
untreated hyperthyroidism. The nurse should expect to find a(n)
__________ pulse.
a. Normal
b. Absent
c. Bounding
d. Weak, thready
ANS: C
A full, bounding pulse occurs with hyperkinetic states (e.g., exercise,
anxiet y, fever), anemia, and h yperthyroidism. An absent pulse occurs
with occlusion. Weak, thready pulses occur with shock and peripheral
artery disease.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 517
MSC: Client Needs: Physiologic Integrit y: Physiologic
Adaptation
5. The nurse is preparing to perform a modified Allen test. Which is an
appropriate reason for this test?
a. To measure the rate of l ymphatic drainage
b. To evaluate the adequacy of capillary patency before venous blood
draws
S YSTEM
MULTIPLE CHOICE
1. The nurse is performing an assessment on an adult. The adults vital signs
are normal, and capillary refill time is 5 seconds. What should the nurse
do next?
a. Ask the patient about a history of frostbite.
b. Suspect that the patient has venous insufficiency.
c. Consider this a delayed capillary refill time, and investigate further.
d. Consider this a normal capillary refill time that requires no further
assessment.
ANS: C
Normal capillary refill time is less than 1 to 2 seconds. The following
conditions can skew the findings: a cool room, decreased body
temperature, cigarette smoking, peripheral ede ma, and anemia.
DIF: Cognitive Level: Anal yzing (Anal ysis) REF: p. 516
MSC: Client Needs: Health Promotion and Maintenance
2. When assessing a patient, the nurse notes that the left femoral pulse as
diminished, 1+/4+. What should the nurse do next?
a. Document the finding.
b. Auscultate the site for a bruit.
, c. Check for calf pain.
d. Check capillary refill in the toes.
ANS: B
If a pulse is weak or diminished at the femoral site, then the nurse
should auscultate for a bruit. The presence of a bruit, or turbulent
blood flow, indicates partial occlusion. The other responses are not
correct.
DIF: Cognitive Level: Anal yzing (Anal ysis) REF: p. 521
MSC: Client Needs: Safe and Effective Care Environment:
Management of Care
3. When performing a peripheral vascular asses sment on a patient, the nurse
is unable to palpate the ulnar pulses. The patients skin is warm and
capillary refill time is normal. Next, the nurse should:
a. Check for the presence of claudication.
b. Refer the individual for further evaluation.
c. Consider this finding as normal, and proceed with the peripheral
vascular evaluation.
d. Ask the patient if he or she has experienced any unusual cramping
or tingling in the arm.
ANS: C
Palpating the ulnar pulses is not usuall y necessary. The ulnar pulses
are not often palpable in the normal person. The other responses are
not correct.
, DIF: Cognitive Level: Anal yzing (Anal ysis) REF: p. 517
MSC: Client Needs: Safe and Effective Care Environment:
Management of Care
4. The nurse is assessing the pulses of a patient who has been admitted for
untreated hyperthyroidism. The nurse should expect to find a(n)
__________ pulse.
a. Normal
b. Absent
c. Bounding
d. Weak, thready
ANS: C
A full, bounding pulse occurs with hyperkinetic states (e.g., exercise,
anxiet y, fever), anemia, and h yperthyroidism. An absent pulse occurs
with occlusion. Weak, thready pulses occur with shock and peripheral
artery disease.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 517
MSC: Client Needs: Physiologic Integrit y: Physiologic
Adaptation
5. The nurse is preparing to perform a modified Allen test. Which is an
appropriate reason for this test?
a. To measure the rate of l ymphatic drainage
b. To evaluate the adequacy of capillary patency before venous blood
draws
