While completing an admission assessment, the nurse is unable to palpate the client's left dorsalis pedis (DP) pulse. Which intervention is most important for the nurse to implement?

Use a doppler to assess an audible DP pulse.

Place a mark where DP pulse is auscultated.

Review client's history for vascular disease.

Assess capillary refill distal to the DP pulse.

Answer and Explanation

The Correct Answer is A

A) Use a doppler to assess an audible DP pulse:
Using a doppler to assess an audible DP pulse may provide additional information about the presence or absence of the pulse, but it does not address the underlying cause of the absent pulse. It is important to first investigate potential causes, such as vascular disease, before resorting to additional assessment techniques.

B) Place a mark where DP pulse is auscultated:
Marking the location where the DP pulse is auscultated may assist with future assessments but does not address the underlying reason for the absent pulse. It is essential to determine the cause of the absent pulse before considering further interventions.

C) Review client's history for vascular disease:
Reviewing the client's history for vascular disease is the most important intervention in this scenario. Absence of a DP pulse may indicate peripheral vascular disease or other circulatory issues. Reviewing the client's history for risk factors such as diabetes, hypertension, smoking, or previous vascular problems can provide valuable information to guide further assessment and management.

D) Assess capillary refill distal to the DP pulse:
Assessing capillary refill distal to the DP pulse is important for evaluating peripheral perfusion but may not directly address the underlying cause of the absent pulse. While assessing capillary refill is a valuable assessment, reviewing the client's history for vascular disease takes precedence in determining the cause of the absent DP pulse.

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Correct Answer is A

Explanation

A) Initiate NPO status: The client's sudden cessation of breathing during deep palpation of the abdomen suggests peritoneal irritation, which could be indicative of a serious condition such as appendicitis or peritonitis. Initiating NPO (nothing by mouth) status is crucial in case emergency surgery is required to address the underlying abdominal pathology. NPO status helps prevent complications such as aspiration if surgery becomes necessary.

B) Restrict activity to bed rest: While bed rest may be indicated for certain abdominal conditions to reduce discomfort and prevent exacerbation of symptoms, it is not the most immediate priority in this scenario. The priority is addressing the potential need for emergency surgery and ensuring the client's safety.

C) Monitor urinary output: Monitoring urinary output is important for assessing hydration status and renal function, but it is not the most critical intervention in this scenario where peritoneal irritation is suspected.

D) Obtain an electrocardiogram: While an electrocardiogram (ECG) may be warranted in certain situations, such as if the client is experiencing chest pain or symptoms suggestive of cardiac involvement, it is not indicated as the most immediate action in this scenario of acute abdominal pain and potential peritoneal irritation.

A. Ask the client to complete a common proverb or saying. B. Have the client repeat a phrase containing alliteration. C. Note the client's responses during the initial interview. D. Listen while the client reads items listed on the menu.

Correct Answer is C

Explanation

A) Ask the client to complete a common proverb or saying:
While completing a common proverb or saying can provide some insight into speech patterns, it may not offer a comprehensive assessment of the client's speech abilities. Additionally, the client's familiarity with specific proverbs or sayings could influence their performance.

B) Have the client repeat a phrase containing alliteration:
Having the client repeat a phrase containing alliteration can assess specific aspects of speech, such as articulation and fluency. However, it may not provide a holistic assessment of speech patterns and may not be suitable for all clients.

C) Note the client's responses during the initial interview:
This approach allows the nurse to observe the client's spontaneous speech patterns, including articulation, fluency, rate, and coherence, during the natural flow of conversation. It provides a comprehensive assessment of speech abilities in various contexts.

D) Listen while the client reads items listed on the menu:
While listening to the client read items on a menu can assess reading ability and pronunciation, it may not fully capture speech patterns in spontaneous conversation or communication. Additionally, it may not be relevant to clients who may have difficulty reading or have limited literacy skills.

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While completing an admission assessment, the nurse is unable to palpate the client's left dorsalis pedis (DP) pulse. Which intervention is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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