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NR 304 Exam 1 Concepts Questions And Answers 2024 Verified Study Solutions
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NR 304 Exam 1 Concepts Questions And Answers 2024 Verified Study Solutions How does once perform a capillary refill assessment? - Depress and blanch nail beds - Hold for 5 seconds - Release depression of nail bed What is the capillary refill assessment an indicator of? - peripheral perfusion ...

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  • August 30, 2024
  • 21
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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NR 304 Exam 1 Concepts Questions And Answers
2024 Verified Study Solutions
How does once perform a capillary refill assessment?

- Depress and blanch nail beds
- Hold for 5 seconds
- Release depression of nail bed

What is the capillary refill assessment an indicator of?

- peripheral perfusion status

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What should a nurse note during an capillary refill assessment?

- Time capillaries took to refill

What is a normal refill rate of a capillary refill assessment?

- < 1-2 seconds

What are some subjective data when it comes to venous (stasis ulcers)?

- Aching pain in lower leg / calf
- itching w/ stasis dermatitis

What makes the aching pain associated with venous ulcers worse?

- prolonged standing
- prolonged sitting

What is some objective data you would note with venous disease / insufficiency (stasis ulcers)?

,- Lower extremity edema
- brawny edema
- coarse, thickened skin
- normal pulse
- brown pigment discoloration
- Petechiae
- Dermatitis
- shallow granulation

What does venous ulcers cause an increase in?

- venous pressure

What are some clinical manifestations of peripheral arterial disease (PAD)?

- Leg pain
- Cramps
- Skin colorization change in arms/ legs
- swelling in arms / legs
- lymph node enlargement
- fatigue
- Claudication
- Night pain
- Coolness to touch
- paralysis

What is poikilothermic?

Coolness to the touch

What does claudication mean?

- pain while walking

What clinical manifestation would be noted if PAD was severe?

- paralysis

What is the pulse associated with arterial insufficiency/ disease (PAD)

- Weak/ Thready pulses
- 1 + pulse
- Diminished pulses

What is the pule associated with Venous disease?

- Bounding force
-3+

What are some relieving factors for arterial insufficiency / disease (PAD)?

- Rest
- Dangling feet

How long does resting take to relieve arterial disease (PAD)?

, - 2 minutes

When should a nurse use the feet dangling method to cause relief for PAD?

- when PAD is severe

What are some relieving factors associated with Venous insufficiency/ disease?

- Elevation
- Lying
- Walking
- pain meds

What does intermittent claudication mean?

- pain impacting the calf muscle

What does claudication distance mean?

- Specific number of blocks / stairs that can be met before pain is observed

What are some signs of worsening claudication?

- Cold feet
- Cramping
- Tingling
- Numbness

What are some subjective data examples of arterial ulcers?

- Deep pain in the calf
- Claudication
- Worsening pain with elevation

Where is the pain located in arterial ulcers normally?

- deep in the calf

What is claudication associated with?

- Peripheral vascular disease
- Arterial ulcers

What impacts does elevation cause on a patient with arterial ulcers?

- increases pain of arterial ulcers

What impacts does elevation cause on a patient with venous ulcers?

- decreases pain of venous ulcers

What are some objective data that is associated to arterial ulcers?

- coolness in only one foot or leg
- pallor
- elevational pallor
- dependent rubor

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