A nurse is assessing a client. Which of the following actions should the nurse take to assess the posterior tibial pulse? (Select all that apply.)

Palpate the area behind the ankle bone.

Use the pads of the fingers to feel for the pulse.

Compare the pulse strength with the other leg.

Assess for any swelling or tenderness

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale

Palpate the area behind the ankle bone. This action is correct. The posterior tibial pulse is located behind the medial malleolus (ankle bone), and palpating this area is necessary to assess the pulse.

Choice B rationale

Use the pads of the fingers to feel for the pulse. This action is correct. Using the pads of the fingers provides a more sensitive and accurate assessment of the pulse compared to using the fingertips or thumb.

Choice C rationale

Compare the pulse strength with the other leg. This action is correct. Comparing the pulse strength bilaterally helps identify any discrepancies that may indicate vascular issues.

Choice D rationale

Assess for any swelling or tenderness. This action is incorrect. While assessing for swelling or tenderness is essential in a general physical examination, it is not a specific step in assessing the posterior tibial pulse.

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Correct Answer is ["B","D","E"]

Explanation

Choice B rationale

Nausea is a common symptom of digoxin toxicity. Elevated levels of digoxin can lead to gastrointestinal disturbances, including nausea, vomiting, and loss of appetite.

Choice D rationale

Seeing halos around bright objects is a classic sign of digoxin toxicity. This visual disturbance, along with blurred vision and yellow-green vision, indicates that the digoxin level is too high.

Choice E rationale

Photophobia, or sensitivity to light, can also be a symptom of digoxin toxicity. This occurs due to the effects of digoxin on the visual system.

A. Fat neck veins. B. Hypotension. C. Poor skin turgor. D. Bradycardia. E. Pale yellow urine.

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale

Fat neck veins are not a typical finding in a client with frequent vomiting and diarrhea. Dehydration, which is common in such cases, usually leads to flat neck veins due to reduced intravascular volume.

Choice B rationale

Hypotension is a common finding in clients with frequent vomiting and diarrhea due to fluid loss and dehydration. The loss of fluids leads to a decrease in blood volume, resulting in low blood pressure.

Choice C rationale

Poor skin turgor is a classic sign of dehydration, which is expected in clients with frequent vomiting and diarrhea. Dehydration causes the skin to lose its elasticity, leading to poor skin turgor.

Choice D rationale

Bradycardia is not typically associated with dehydration. In fact, dehydration often leads to tachycardia (increased heart rate) as the body tries to compensate for the reduced blood volume.

Choice E rationale

Pale yellow urine is not a typical finding in dehydration. Dehydration usually leads to concentrated urine, which is darker in color. Pale yellow urine indicates adequate hydration.

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A nurse is assessing a client. Which of the following actions should the nurse take to assess the posterior tibial pulse? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","D","E"]

Explanation

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Correct Answer is ["B","C","E"]

Explanation

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