The nurse assesses the client as shown. What pulse is the nurse assessing?
Posterior tibial
Femoral
Popliteal
Dorsalis pedis
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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Related Questions
Correct Answer is D
Explanation
A. Thigh muscles: While thigh muscles assist in venous return, they are not as critical as the calf muscles in moving blood from the feet.
B. Arterial pulsations: Arterial pulsations help in the forward movement of blood in the arteries but do not directly assist with venous return from the feet.
C. Venous flow: Venous flow is the general term for blood movement in veins, but it does not specify the mechanism responsible for moving blood from the feet.
D. Calf muscles: The calf muscles, through their contraction (often referred to as the "muscle pump"), are crucial in helping to push blood upwards from the feet towards the inferior vena cava. This mechanism is essential for effective venous return.
Correct Answer is A
Explanation
A. I: A grade I murmur is very faint and may not be heard immediately without careful listening. The description of a murmur heard immediately upon placing the stethoscope indicates it is a grade I.
B. X: There is no grade X in the standard grading scale for heart murmurs.
C. II: A grade II murmur is quiet but easily heard with a stethoscope and would generally be more audible than described.
D. III: A grade III murmur is moderately loud and would be heard without difficulty. The description suggests a quieter murmur.
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