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 C

Explanation

Choice A rationale

Friction rub is not a typical complication of endocarditis. It is more commonly associated with pericarditis, which is inflammation of the pericardium.

Choice B rationale

Intermittent claudication is not a complication of endocarditis. It is typically associated with peripheral artery disease, which affects blood flow to the limbs.

Choice C rationale

Cardiac murmur is a common finding in endocarditis. The infection can cause damage to the heart valves, leading to abnormal heart sounds or murmurs.

Choice D rationale

Dependent rubor is not a complication of endocarditis. It is usually associated with peripheral artery disease and is characterized by redness of the lower extremities when they are in a dependent position.

A. A client whose daily caloric intake is 25% fat. B. A client who has diabetes mellitus. C. A client who consumes two 12-ounce (0.35-L) alcoholic beverages daily. D. A client who has hypothyroidism.

Correct Answer is B

Explanation

Choice A rationale

A daily caloric intake of 25% fat is within the recommended range and does not significantly increase the risk for peripheral arterial disease (PAD).

Choice B rationale

Diabetes mellitus is a significant risk factor for PAD. High blood sugar levels can damage blood vessels and lead to poor circulation.

Choice C rationale

Consuming two 12-ounce alcoholic beverages daily can contribute to other health issues but is not a primary risk factor for PAD.

Choice D rationale

Hypothyroidism is not directly linked to an increased risk of PAD. It can cause other cardiovascular issues but not specifically PAD.

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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 C

Explanation

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Correct Answer is B

Explanation

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