Author Question: The nurse is performing a head-to-toe assessment on a resident in a long-term care facility with a ... (Read 601 times)

pragya sharda · **on:** Jul 24, 2018

The nurse is performing a head-to-toe assessment on a resident in a long-term care facility with a history of angina pectoris. When assessing peripheral perfusion, the nurse will perform which intervention(s)? (Select all that apply.)

a. Count heart rate and describe rhythm.
b. Note any loss of hair on lower legs.
c. Auscultate blood pressure.
d. Check pedal pulses.
e. Assess pupil reaction.

Question 2

The nurse is assessing the patient's leg for peripheral vascular disease (PVD) and is unable to palpate the pedal pulse in either foot. Which action will the nurse take first?

a. Contact the health care provider for further orders.
b. Request x-ray studies of the lower extremities.
c. Request that the patient lie flat.
d. Obtain a Doppler ultrasound device for auscultation.

Leostella20 · **Reply #1 on:** Jul 24, 2018

Answer to Question 1

ANS: B, D
Peripheral perfusion assessment includes noting loss of hair on lower legs, denoting decreased circulation. When assessing peripheral perfusion, the pedal pulses in the lower extremities are assessed in conjunction with skin color and temperature. Heart rate and rhythm are components of assessment of the cardiovascular system but not associated with peripheral tissue perfusion. Pupil reaction is considered a neurologic assessment.

Answer to Question 2

ANS: D
The Doppler ultrasound device may aid in determining peripheral blood flow. This is not a sufficient cause to notify the health care provider and does not warrant radiologic examination without further assessment. Positioning will not affect the assessment of pedal pulses.