If unable to locate the client’s popliteal pulse during a routine examination, what should the nurse do next?

Check for a pedal pulse.

Check for a femoral pulse.

Take the client’s blood pressure on that thigh.

Ask another nurse to try to locate the pulse.

Answer and Explanation

The Correct Answer is A

Peripheral pulse assessment is a critical component of the circulatory examination. Nurses evaluate the strength, rate, rhythm, and presence of pulses to determine adequate blood flow to the extremities.

Rationale for correct answer:

1. Check for a pedal pulse: If the popliteal pulse is absent or difficult to palpate, the nurse should immediately check distal pulses, such as the dorsalis pedis or posterior tibial pulses, to assess whether circulation is intact below the knee.

Rationale for incorrect answers:

2. Check for a femoral pulse: While checking the proximal (femoral) pulse might be appropriate after distal pulses are absent or diminished, it is not the immediate next step. First, the nurse should assess whether blood flow continues beyond the popliteal area by checking distal pulses.

3. Take the client’s blood pressure on that thigh: Thigh blood pressure is not typically indicated for routine peripheral pulse evaluation and may be technically difficult or inaccurate without specialized equipment (e.g., thigh cuff, Doppler).

4. Ask another nurse to try to locate the pulse: While collaboration can be helpful, the nurse should first complete their own assessment, starting with other distal pulses. Asking for help is secondary unless there's uncertainty or need for confirmation after following proper protocol.

Take-home points

If a peripheral pulse is not palpable, always check a more distal pulse next to evaluate if blood flow continues beyond the affected site.
The presence of distal pulses (e.g., dorsalis pedis or posterior tibial) indicates that circulation is adequate, even if the popliteal pulse cannot be felt.

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Free Nursing Study Resources

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

Explanation

After a femoral artery bypass, careful monitoring of distal perfusion is critical to detect signs of occlusion or ischemia early. One of the most important parameters is the assessment of distal pulses, such as the dorsalis pedis pulse, which provides information about blood flow to the lower extremities.

Rationale for correct answers:

2. Have the patient slightly flex the knee with the foot resting on the bed: Slightly flexing the knee and allowing the foot to rest on the bed relaxes the muscles of the lower leg and foot, making it easier to palpate the dorsalis pedis pulse on the dorsum (top) of the foot.

3. Have the patient relax the foot while lying supine: The dorsalis pedis pulse is best palpated when the client is in a supine position with the foot relaxed. This ensures muscles are not contracted, which could make the pulse more difficult to detect.

Rationale for incorrect answers:

1. Place the fingers behind and below the medial malleolus: This technique is used to palpate the posterior tibial pulse, not the dorsalis pedis pulse. The posterior tibial artery runs behind the medial malleolus (inner ankle), while the dorsalis pedis artery is located on the top of the foot.

4. Palpate the groove lateral to the flexor tendon of the wrist: This describes the technique for assessing the radial pulse, which is located on the wrist. It is unrelated to the dorsalis pedis pulse or assessing lower extremity circulation.

Take home points:

The dorsalis pedis pulse is located on the top of the foot, lateral to the extensor hallucis longus tendon.
It is best assessed with the patient lying supine and the foot relaxed.
Post-femoral artery bypass, monitoring distal pulses like the dorsalis pedis is essential to ensure graft patency and detect early signs of limb ischemia.

A. Facial hair that becomes finer and softer B. Decreased peripheral, color, and night vision C. Increased sensitivity to odors D. An irregular respiratory rate and rhythm at rest

Correct Answer is B

Explanation

Aging brings about predictable and progressive physiological changes in all body systems. These changes are not necessarily indicative of disease but represent a normal part of the aging process.

Rationale for correct answer:

2. Decreased peripheral, color, and night vision: Older adults commonly experience: Decreased peripheral vision (due to retinal changes), Reduced color discrimination (particularly blues and greens), Poorer night vision (due to reduced pupil size and lens transparency).

Rationale for incorrect answers:

1.Facial hair that becomes finer and softer: In older adults, especially women, facial hair may actually become coarser and more noticeable due to hormonal changes, particularly decreased estrogen and relative androgen excess.

3. Increased sensitivity to odors: Olfactory sensitivity declines with age due to loss of olfactory neurons and decreased mucosal receptors. Older adults often have reduced ability to detect and distinguish smells, which can affect appetite and safety (e.g., detecting gas leaks or spoiled food).

4. An irregular respiratory rate and rhythm at rest: While the respiratory system ages (e.g., decreased lung elasticity and vital capacity), a regular rate and rhythm is still expected at rest.

Take home points

Decreased peripheral, color, and night vision are expected in older adults due to physiological changes in the eye (e.g., presbyopia, retinal thinning, and lens clouding).
Unexpected changes in respiratory rhythm or heightened smell sensitivity are not normal with aging and should prompt further clinical evaluation.

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If unable to locate the client’s popliteal pulse during a routine examination, what should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has undergone surgery for a femoral artery bypass. The surgeon’s orders include assessment of dorsalis pedis pulses. The nurse will use which of the following techniques to assess the pulses? Select all that apply

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

Explanation

Which of the following is an expected finding during assessment of the older adult?

Correct Answer is B

Explanation

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