The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up?

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.

In physical assessment, client positioning is crucial for accurate inspection, palpation, percussion, and auscultation. The nurse selects positions that provide the best access to anatomical areas while maintaining client comfort and dignity.

Rationale for correct answer:

3. Breast: Palpation of the breasts is commonly performed with the client in multiple positions, including sitting upright, particularly during inspection and palpation of the axillary (underarm) area and lymph nodes.

Rationale for incorrect answers:

1. Abdomen: The abdomen is best palpated with the client in the supine position, lying flat with knees slightly flexed. This relaxes the abdominal muscles and provides optimal access to all four quadrants for light and deep palpation.

2. Genitals: Genital examination typically requires the lithotomy position for females (lying on back with legs elevated and supported) or standing or supine for males, depending on the purpose (e.g., hernia exam or testicular palpation).

4. Head and neck: While inspection of the head and neck is commonly done with the client sitting upright, palpation (e.g., of lymph nodes, thyroid gland) is often performed with the client sitting but with the head slightly tilted or extended, not strictly upright.

Take home points

• The sitting upright position is used during breast palpation, especially when assessing axillary tissue and lymph nodes.
• Proper positioning varies by assessment area.