When assessing a patient, the nurse notes that the left femoral ...

[magmichele12]

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.

Question 2

The nurse is performing an assessment on an adult. The adult's 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.

[upturnedfurball]

Answer to Question 1

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.

Answer to Question 2

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 edema, and anemia.

[magmichele12]

Thank you

[upturnedfurball]

No problemo