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: While the client's medical history and admission assessment provide valuable information, they do not directly measure the current pain experience.
Choice B reason: Vital signs can indicate pain but are not a definitive measure of pain severity as they can be influenced by other factors.
Choice C reason: The frequency of analgesic administration may suggest the level of pain control but does not measure the current pain intensity experienced by the client.
Choice D reason: Asking the client to describe the intensity of the pain is the most direct and effective way to assess pain severity. Pain is subjective, and the client's self-report is considered the gold standard for pain assessment.
Correct Answer is C
Explanation
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.
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