The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. What would be most appropriate for the nurse to do next?
Auscultate the anatomic area with a stethoscope.
Use Doppler ultrasonography to locate the pulse.
Ask another nurse to assess the pulse.
Document absence of dorsalis pedis pulse.
The Correct Answer is B
A. Auscultating the area may not provide accurate information about the pulse if it is not palpable, though it can be part of the assessment if Doppler is unavailable.
B. Using Doppler ultrasonography is the most appropriate next step to accurately assess the pulse if it is not palpable, especially in older adults where pulses may be difficult to detect.
C. Asking another nurse to assess the pulse may not address the underlying issue of why the pulse is not palpable and does not provide additional information.
D. Documenting the absence of the dorsalis pedis pulse without further investigation could be premature, as Doppler ultrasonography should be used to confirm its absence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Diverticulosis: Murphy's sign is not used to diagnose diverticulosis.
B. Acute Cholecystitis: Murphy's sign is a clinical test used to identify acute cholecystitis. It is positive when the patient experiences pain upon palpation of the gallbladder area during inhalation.
C. Appendicitis: Murphy's sign is not associated with appendicitis; instead, other signs such as McBurney’s point tenderness are used.
D. Nephrolithiasis: Murphy's sign is not indicative of nephrolithiasis; kidney stones are assessed through other signs and symptoms.
Correct Answer is D
Explanation
A. Thigh muscles: While thigh muscles assist in venous return, they are not as critical as the calf muscles in moving blood from the feet.
B. Arterial pulsations: Arterial pulsations help in the forward movement of blood in the arteries but do not directly assist with venous return from the feet.
C. Venous flow: Venous flow is the general term for blood movement in veins, but it does not specify the mechanism responsible for moving blood from the feet.
D. Calf muscles: The calf muscles, through their contraction (often referred to as the "muscle pump"), are crucial in helping to push blood upwards from the feet towards the inferior vena cava. This mechanism is essential for effective venous return.
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