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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["C","D"]

Explanation

Choice A rationale: A shuffling gait increases fall risk but does not directly impair ability to perform foot care or toenail trimming, so UAP assignment is not primarily indicated here.

Choice B rationale: Urinary incontinence affects bladder control, not manual dexterity or safety during foot care. It does not necessitate UAP assistance for toenail trimming or routine foot care.

Choice C rationale: Syncope when bending increases risk of fainting during foot care tasks, making independent toenail trimming unsafe. UAP support ensures safety and prevents injury during routine care.

Choice D rationale: Hand tremors impair fine motor control, making toenail trimming difficult and unsafe. UAP assistance is indicated to prevent injury and ensure proper routine foot care.

A. Explain that since the medication is a controlled substance, it must be taken. B. Credit the medication back and put it in the client's medication box. C. Keep the medication and see if the client will want to take it later. D. Have another nurse witness the disposal of the medication into the disposal container.

Correct Answer is D

Explanation

Choice A reason: The nurse cannot force the client to take medication against their will, even if it is a controlled substance.

Choice B reason: Crediting the medication back and placing it in the client's medication box is not appropriate as the medication has already been removed from the unit dose wrapper.

Choice C reason: Keeping the medication to see if the client will want to take it later is not safe practice as it could lead to medication errors or misuse.

Choice D reason: The nurse should dispose of the medication properly, and having another nurse witness the disposal is a standard procedure to ensure that controlled substances are accounted for.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails? Select all that apply.

Correct Answer is ["C","D"]

Explanation

The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?

Correct Answer is D

Explanation

The nurse observes an unlicensed assistive personnel (UAP) providing care for two clients using the same gloves. Which action should the nurse take first?

During the admission assessment to the hospital, an adult client reports being allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?

When conducting diet teaching for a client who is on a postoperative clear liquid diet, which foods should the nurse encourage the client to consume? Select all that apply.

The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during respiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?

The nurse is providing postoperative teaching to a client on ways to prevent constipation. Which information should the nurse include?

A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?

A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient's fluid balance?