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.

Answer and Explanation

The Correct Answer is A

Choice A rationale: Excessive pressure can occlude arterial flow, preventing detection of the dorsalis pedis pulse. Reducing pressure allows blood flow to be felt, improving accuracy of pulse assessment.

Choice B rationale: Documentation without rechecking risks inaccurate reporting. Pulses may be present but obscured by technique, so confirming with proper palpation or alternative methods is necessary before recording findings.

Choice C rationale: Doppler stethoscope is useful but should be considered after correcting palpation technique. Initial step is adjusting pressure, as improper technique commonly explains absent pulse detection.

Choice D rationale: Palpating posterior tibial pulse assesses a different artery. While useful for circulation evaluation, it does not address the immediate issue of dorsalis pedis pulse palpation technique.

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Correct Answer is D

Explanation

Choice A reason: Printing the EMR from a backup server does not resolve the immediate issue of the system lockup and may not be possible if the system is down.

Choice B reason: Identifying information as a late entry is a step to take after the system issue has been resolved and does not address the current problem.

Choice C reason: Waiting for the system to be rebooted is passive and does not actively contribute to resolving the system lockup.

Choice D reason: Notifying the information services department is the first and most proactive step to take, as they are responsible for resolving technical issues with the EMR system.

A. Teach the client alternative ways to manage chronic pain. B. Instruct the client to take the morphine sulfate every 12 hours as prescribed. C. Tell the client to continue taking the morphine sulfate with severe pain. D. Explain the risk of drug addiction from long-term pain medications.

Correct Answer is B

Explanation

Choice A reason: While teaching alternative ways to manage pain is important, it does not address the immediate issue of the client not taking the medication as prescribed.

Choice B reason: The client should be instructed to take the medication as prescribed to maintain consistent pain control and prevent breakthrough pain.

Choice C reason: Advising the client to take the medication only with severe pain is contrary to the prescribed regimen and could lead to inadequate pain management.

Choice D reason: It is important to discuss the risks of long-term medication use, but the priority is to ensure that the client understands the importance of taking the medication as prescribed for effective pain management.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is entering prescriptions for laboratory work in a client's electronic medical record (EMR) when the system locks up and does not restart. Which action should the nurse take first?

Correct Answer is D

Explanation

An older adult client returns to the clinic for chronic pain management after taking morphine sulfate 25 mg PO every 12 hours. The client reports taking the medication only when the pain was too severe to sleep. Which action should the nurse implement?

Correct Answer is B

Explanation

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