Author Question: During an assessment, the nurse has elevated a patient's legs 12 inches off the table and has had ... (Read 28 times)

rayancarla1 · **on:** Jun 25, 2018

During an assessment, the nurse has elevated a patient's legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him sit up and dangle his legs over the side of the table,

the nurse should expect that a normal finding at this point would be:
a.
Significant elevational pallor.
b.
Venous filling within 15 seconds.
c.
No change in the coloration of the skin.
d.
Color returning to the feet within 20 seconds of assuming a sitting position.

Question 2

When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration.

a. Alternans.
b. Bisferiens.
c. Bigeminus.
d. Paradoxus.

Moriaki · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: B
In this test, it normally takes 10 seconds or less for the color to return to the feet and 15 seconds for the veins of the feet to fill. Significant elevational pallor, as well as delayed venous filling, occurs with arterial insufficiency.

Answer to Question 2

ANS: D
In pulsus paradoxus, beats have weaker amplitude with inspiration and stronger amplitude with expiration and is best determined during blood pressure measurement; reading decreases (>10 mm Hg) during inspiration and increases with expiration.