A nurse is unable to palpate a client's dorsalis pedis pulse. The nurse will next attempt to palpate the
Carotid pulse
Brachial pulse
Posterior tibialis
Femoral pulse
The Correct Answer is C
A: This is not suitable for assessing circulation issues specifically in the lower extremities as it is located on the upper body.
B: This is not suitable for assessing circulation issues specifically in the lower extremities as it is located on the upper body.
C: Palpating the posterior tibialis pulse is a logical next step for checking lower extremity circulation, particularly when dorsalis pedis is not palpable, helping localize the evaluation of blood flow in the foot and ankle.
D: The femoral pulse is useful for broader leg circulation issues. However, it is less targeted than posterior tibialis for checking blood flow in the lower extremities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: To accurately determine a pulse deficit, one nurse must listen to the apical pulse while another nurse palpates the radial pulse simultaneously to compare both pulse rates, necessitating a second person.
B: Counting the apical pulse is a part of the process but would follow after ensuring another nurse is available to check the radial pulse at the same time.
C: This action relates to checking a pulse rate generally but does not specify the need for simultaneous comparison with the apical pulse.
D: Calculation of the difference is the final step after both pulses have been counted simultaneously.
Correct Answer is D
Explanation
A. Decreased plasma volume might cause overall weak pulses but would unlikely cause an absent pulse specifically localized in one or more extremities. Decreased plasma volume generally affects circulation systemically, not selectively in certain limbs.
B. Problems with the heart's electrical conduction system primarily affect the rhythm and rate of the heart but do not directly cause absent pulses in extremities. These issues lead to irregular or abnormal heartbeats, not localized absence of pulses.
C. Shock can result in weak or thready pulses due to poor blood flow, but shock alone would not typically cause a pulse to be completely absent in one extremity while present in others. Shock affects the circulatory system as a whole.
D. A blockage of blood flow is the most likely cause of an absent pulse in one or more extremities. This could be due to atherosclerosis, embolism, or thrombosis, which can obstruct blood flow in specific areas, leading to no detectable pulse in those extremities.
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