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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
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.
Correct Answer is ["0.5"]
Explanation
Step 1 is (10 mg ÷ 20 mg/mL) = 0.5 mL. The nurse should administer 0.5 mL per dose. .
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