The nurse assesses the client as shown. What pulse is the nurse assessing?

Posterior tibial

Femoral

Popliteal

Dorsalis pedis

Answer and Explanation

The Correct Answer is A

A. Posterior tibial: The posterior tibial pulse is palpated just behind the medial malleolus of the ankle, near the Achilles tendon.
B. Femoral: The femoral pulse is located in the groin area, where the femoral artery passes.
C. Popliteal: The popliteal pulse is palpated behind the knee in the popliteal fossa.
D. Dorsalis pedis: The dorsalis pedis pulse is located on the top of the foot, near the first metatarsal.

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Correct Answer is D

Explanation

A. Perform abdominal percussion, and then repeat auscultation: While percussion can provide additional information, the absence of bowel sounds should first be confirmed by listening for a longer period before moving to other techniques.

B. Palpate the client's abdomen to stimulate bowel motility: Palpation is not recommended to stimulate bowel sounds; it may alter the assessment.

C. Repeat auscultation in four to six hours: Immediate reassessment after five minutes of auscultation is preferable to prolonged waiting.

D. Listen for five minutes before documenting an absence of bowel sounds: To ensure accurate assessment, the nurse should listen for up to five minutes in each quadrant

A. Flat murmur B. Diastolic murmur C. Absent murmur D. Systolic murmur

Correct Answer is D

Explanation

A. A flat murmur does not accurately describe the type of murmur associated with mitral insufficiency.

B. Mitral insufficiency is typically classified as a systolic murmur, not diastolic.

C. An absent murmur would indicate no audible sound, which is not applicable here.

D. Mitral insufficiency or regurgitation is characterized by a systolic murmur due to the backflow of blood from the left ventricle into the left atrium during systole.

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The nurse assesses the client as shown. What pulse is the nurse assessing?

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Naxlex Comprehensive Predictor Exams

The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment?

Correct Answer is D

Explanation

A mitral insufficiency/regurgitation murmur is classified as:

Correct Answer is D

Explanation

The nurse knows screening test(s) for colorectal cancer detection according to recommendations from the American Cancer Society (2018) includes? (Select all that apply.)

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Of the four types of stethoscopes, which one is most unsuitable to conduct a full cardiac examination?

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