The nurse is preparing to assess the posterior tibial pulse.
Where is the correct location for palpation?
In the groove behind the inner ankle.
In the inguinal area.
On top of the foot.
Behind the knee.
The Correct Answer is A
Choice A rationale
The posterior tibial pulse is located in the groove between the medial malleolus (inner ankle bone) and the Achilles tendon. Palpating this pulse requires a gentle but firm touch to identify the arterial pulsations. It is a common site for assessing peripheral circulation and is essential for evaluating lower extremity perfusion.
Choice B rationale
The inguinal area is the anatomical region of the groin, where the femoral pulse is located. The femoral pulse is palpable just below the inguinal ligament, midway between the anterior superior iliac spine and the pubic symphysis. This is a central pulse site, distinct from the posterior tibial pulse.
Choice C rationale
The top of the foot is where the dorsalis pedis pulse is located. This pulse is found lateral to the extensor hallucis longus tendon, over the metatarsal bones. It is another important site for assessing lower extremity perfusion but is different from the posterior tibial pulse.
Choice D rationale
Behind the knee is the location for palpating the popliteal pulse. This pulse is more difficult to assess due to its deep location within the popliteal fossa. It requires the patient's knee to be slightly flexed to relax the muscles and facilitate palpation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The Sims position, also known as left lateral position with the right knee flexed, is ideal for rectal suppository administration. This position allows for optimal visualization and access to the anus, while gravity aids in the retention of the suppository by minimizing premature expulsion.
Choice B rationale
The dorsal recumbent position, where the patient lies on their back with knees flexed and feet flat on the bed, is not optimal for rectal suppository administration. This position makes rectal access difficult and does not utilize gravity to aid in suppository retention, potentially leading to discomfort.
Choice C rationale
The prone position, where the patient lies on their stomach, is not suitable for rectal suppository administration. This position severely limits access to the rectal area, making insertion difficult and uncomfortable for both the patient and the nurse.
Choice D rationale
The supine position, where the patient lies flat on their back, is not ideal for rectal suppository administration. Similar to dorsal recumbent, this position makes adequate visualization and comfortable access to the anus challenging, potentially increasing patient discomfort and insertion difficulty.
Correct Answer is A
Explanation
Choice A rationale
A tuning fork is a U-shaped instrument that, when struck, produces a specific frequency of vibration. In audiology, it is used to assess both air conduction (sound transmitted through the external and middle ear to the inner ear) and bone conduction (sound transmitted directly to the inner ear through the skull), aiding in differentiating types of hearing loss.
Choice B rationale
A penlight is a small, handheld light source primarily used for illuminating body cavities, assessing pupillary reflexes, or examining the oral cavity and throat. It does not produce sound vibrations and is not used for measuring air or bone conduction in the ear.
Choice C rationale
A reflex hammer is an instrument used to elicit deep tendon reflexes by tapping on tendons, stretching the muscle, and activating the reflex arc. It is a neurological assessment tool and has no function in measuring auditory conduction.
Choice D rationale
An otoscope is a medical device equipped with a light and magnifying lens, used for visual examination of the external ear canal and tympanic membrane (eardrum). While essential for ear assessment, it does not measure air or bone conduction; rather, it allows for direct visualization of anatomical structures.
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