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 A

Explanation

Choice A rationale

Weak pedal pulses indicate vascular compromise, which is a complication of Buck’s traction. This can be caused by pressure on the tissues of the leg.

Choice B rationale

Complaints of leg discomfort are expected due to the traction and do not indicate a complication.

Choice C rationale

Toes that are warm and demonstrate brisk capillary refill are normal findings and do not indicate a complication.

Choice D rationale

Drainage at the pin sites is more relevant to skeletal traction, not Buck’s traction.

A. “Eating a high fiber diet will reduce my risk for developing skin cancer.”. B. “I should check my skin monthly for any changes.”. C. “I should avoid the use of tanning booths.”. D. “I should use sunscreen even on cloudy days.”. E. “I should use sunscreen even on cloudy days.”.

Correct Answer is A

Explanation

Choice A rationale

Eating a high fiber diet will reduce my risk for developing skin cancer. This statement is incorrect because a high fiber diet has not been proven to reduce the risk of developing skin cancer. Skin cancer is primarily caused by exposure to ultraviolet (UV) radiation from the sun or artificial sources like tanning booths.

Choice B rationale

I should check my skin monthly for any changes. This statement is correct. Regular self- examinations can help detect skin cancer early when it is most treatable. The American Academy of Dermatology recommends checking your skin from head to toe every month.

Choice C rationale

I should avoid the use of tanning booths. This statement is correct. Tanning booths emit UV radiation, which increases the risk of developing skin cancer. Avoiding tanning booths is a crucial preventive measure.

Choice D rationale

I should use sunscreen even on cloudy days. This statement is correct. UV rays can penetrate clouds, so it is essential to use sunscreen every day, regardless of the weather, to protect the skin from harmful UV radiation.

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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.)

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Naxlex Comprehensive Predictor Exams

The nurse, caring for a client with Buck’s traction, is monitoring the client for complications of the traction. Which assessment finding indicates a complication of this form of traction?

Correct Answer is A

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Correct Answer is A

Explanation

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