NR 304 Study Guide Questions with 100%
Correct Answers
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
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?
Correct Answers
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
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?
