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 D
Explanation
Choice A rationale
Dextrose 5% in water is not recommended for initial fluid resuscitation in burn patients because it does not provide the necessary electrolytes to address the fluid shifts and electrolyte imbalances that occur after a burn injury.
Choice B rationale
0.45% sodium chloride is a hypotonic solution and is not suitable for initial fluid resuscitation in burn patients. It can lead to cellular swelling and does not adequately replace the lost extracellular fluid.
Choice C rationale
Dextrose 5% in 0.9% sodium chloride is not the preferred choice for initial fluid resuscitation in burn patients. While it provides both glucose and electrolytes, it is not as effective as Lactated Ringers in addressing the specific needs of burn patients.
Choice D rationale
Lactated Ringers is the recommended fluid for initial resuscitation in burn patients. It is an isotonic solution that helps to restore circulating volume, correct electrolyte imbalances, and prevent hypovolemic shock.
Correct Answer is B
Explanation
Choice A rationale
Hypervolemia is not typically associated with extensive burn injuries. Burn patients often experience hypovolemia due to fluid loss from the burn wounds.
Choice B rationale
Hyperkalemia is a common finding in patients with extensive burn injuries. The destruction of cells releases potassium into the bloodstream, leading to elevated potassium levels.
Choice C rationale
Low hemoglobin is not a typical finding in the initial phase of burn injury. Hemoglobin levels may decrease later due to blood loss or hemodilution.
Choice D rationale
Metabolic alkalosis is not commonly associated with extensive burn injuries. Burn patients are more likely to experience metabolic acidosis due to tissue hypoxia and lactic acid accumulation.
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