A nurse is monitoring a client's peripheral circulation. Identify where the nurse should palpate to check the posterior tibial pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
The Correct Answer is "{\"xRanges\":[54.328125,79.328125],\"yRanges\":[225.5,250.5]}"
To palpate the posterior tibial pulse, the nurse should place their fingers just behind the medial malleolus, which is the bony prominence on the inner side of the ankle. This is where the posterior tibial artery passes and is a common site for checking peripheral circulation in the lower extremities.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "The client may benefit from a neurology consult." This statement is more appropriate for the recommendation component of SBAR. The background should focus on what has already occurred or is known, not what the nurse thinks should be done next.
B. "The client is disoriented and pupils are slow to respond to light." This would be part of the assessment component of SBAR, which describes the nurse's evaluation of the current condition.
C. "The client has developed drooping facial features." This statement can be included in theSituationcomponent because it describes the immediate concern that prompted the communication.
D. "The client has a history of hypertension." This statement is suitable for theBackgroundcomponent. It provides relevant medical history that helps the provider understand the context of the current situation.
Correct Answer is A
Explanation
A. Count the apical pulsations for a full minute. The apical pulse should be counted for a full minute to ensure accuracy, especially in clients taking cardiovascular medications, as these may affect heart rhythm and rate.
B. Place the stethoscope just under the mid-clavicular area of the left chest. The apical pulse is typically located at the fifth intercostal space at the midclavicular line, not directly under the clavicle.
C. Press the stethoscope firmly against the client's skin. While the stethoscope needs to be in full contact with the skin, excessive pressure is not necessary and may distort the sound.
D. Check the apical pulse with a Doppler device. A Doppler is typically used when the pulse is difficult to palpate or auscultate, not as a first-line method for checking the apical pulse.
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