To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes but does not feel a pulsation. Which action should the nurse take next?
Reduce the amount of pressure being applied on the top of the foot.
Document in the nurse's notes that the dorsalis pedis pulse is not palpable.
Obtain a Doppler stethoscope to auscultate the pulse at the same site.
Palpate the site on the inner side of the ankle below the medial malleolus.
The Correct Answer is C
Choice A reason: Reducing the amount of pressure may not be effective if the pulse is weak or absent; other methods may be needed to assess circulation.
Choice B reason: Documentation is important, but it should be done after all attempts to assess the pulse have been made.
Choice C reason: Using a Doppler stethoscope is a suitable next step when a pulse is not palpable, as it can detect weaker pulses not felt by palpation.
Choice D reason: Palpating the site on the inner side of the ankle below the medial malleolus assesses the posterior tibial pulse, not the dorsalis pedis pulse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Offering comfort that healing can happen at any point in time may not be appropriate for a client in the terminal stage of lung cancer, as it may give false hope.
Choice B reason: Offering strategies to provide comfort to the client can be helpful, but it does not address the spouse's immediate emotional needs.
Choice C reason: Suggesting that the spouse go home to sleep may seem dismissive of the spouse's current emotional state and need for support.
Choice D reason: Explaining that the staff will strive to keep the client comfortable addresses the spouse's concern for the client's well-being and provides reassurance about the care being provided.
Correct Answer is B
Explanation
Choice A reason: The Trendelenburg position is not indicated for increasing oxygen saturation and could be harmful, especially for clients with respiratory distress.
Choice B reason: Ensuring that the prongs of the nasal cannula are securely placed in the nostrils is important for effective oxygen delivery, especially if the oxygen saturation remains below the prescribed range.
Choice C reason: Placing the pulse oximeter on the client's earlobe is an alternative site for obtaining a saturation reading, but it does not address the issue of potentially inadequate oxygen delivery.
Choice D reason: While documentation is important, the nurse must first address the low oxygen saturation levels before documenting the readings.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today