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A client has been diagnosed with peripheral arterial insufficiency to the right leg. Which of these findings would the nurse expect to find with this condition?

A.

Skin cool to the touch

B.

Healthy nail appearance

C.

Skin warm and dry

D.

Pulse is 2+

E.

Leg appears swollen

Answer and Explanation

The Correct Answer is A

A. In peripheral arterial insufficiency, blood flow is reduced, leading to cooler skin temperatures, especially in the affected extremity.

 

B. Nail appearance may be unhealthy due to poor perfusion; nails may become thickened or grow slowly.

 

C. Skin is typically cool and may be dry, not warm, indicating reduced blood flow.

 

D. A pulse of 2+ is within normal range; however, pulses may be diminished or absent in cases of significant arterial insufficiency.

 

E. The leg typically does not appear swollen; rather, it may show signs of atrophy or hair loss due to inadequate blood supply.


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View Related questions

Correct Answer is B

Explanation

A. 3+ edema indicates moderate pitting (indentation depth of 5-7 mm and lasting 10-20 seconds).

B. 1+ edema is classified as slight pitting (indentation depth less than 2 mm that disappears rapidly, typically in less than 10 seconds), making this the correct documentation.

C. 2+ edema indicates moderate pitting (indentation depth of 3-4 mm that lasts up to 15 seconds).

D. +0 indicates no edema present at all.

E. 4+ edema indicates severe pitting (indentation depth of greater than 8 mm and lasting more than 20 seconds).

Correct Answer is E

Explanation

A. Calling another nurse for help is unnecessary unless additional assistance is required after initial interventions.

B. Giving pain medication as ordered may address the chest pain but does not address the immediate need for oxygenation.

C. Calling the admitting healthcare provider can be done later if symptoms do not improve, but the immediate priority is to improve oxygenation.

D. Telling the client to remain calm may help reduce anxiety but does not address the low oxygen saturation.

E. Applying oxygen via nasal cannula as ordered is the priority action to improve the client’s oxygen saturation and alleviate hypoxemia, which could be contributing to their chest pain.

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