To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes but does not feel a pulsation. Which action should the nurse take next?

Reduce the amount of pressure being applied on the top of the foot.

Document in the nurse's notes that the dorsalis pedis pulse is not palpable.

Obtain a Doppler stethoscope to auscultate the pulse at the same site.

Palpate the site on the inner side of the ankle below the medial malleolus.

Answer and Explanation

The Correct Answer is C

Choice A reason: Reducing the amount of pressure may not be effective if the pulse is weak or absent; other methods may be needed to assess circulation.

Choice B reason: Documentation is important, but it should be done after all attempts to assess the pulse have been made.

Choice C reason: Using a Doppler stethoscope is a suitable next step when a pulse is not palpable, as it can detect weaker pulses not felt by palpation.

Choice D reason: Palpating the site on the inner side of the ankle below the medial malleolus assesses the posterior tibial pulse, not the dorsalis pedis pulse.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Even without mentioning the client's name, discussing health information in a public area like a breakroom can still lead to a HIPAA violation due to the possibility of revealing identifiable information indirectly.

Choice B reason: Discussing health history with a client behind a closed curtain maintains privacy and confidentiality, adhering to HIPAA regulations.

Choice C reason: Faxing health records to a client's primary healthcare provider is a common practice and is not a HIPAA violation if done securely and with proper consent.

Choice D reason: Sharing a client's discharge needs with other treatment team members is necessary for continuity of care and is not a HIPAA violation as long as it is done within the healthcare team.

A. Modify the nursing interventions to achieve the client's goals. B. Determine if the expected outcomes were realistic. C. Obtain current client data to compare with expected outcomes. D. Review related professional standards of care.

Correct Answer is C

Explanation

Choice A reason: Modifying nursing interventions is a step that may be necessary after evaluating the effectiveness of care, but it is not the immediate next action after reviewing the expected outcomes.

Choice B reason: Determining if the expected outcomes were realistic is part of the evaluation process, but it requires current data to make an informed decision.

Choice C reason: Obtaining current client data is essential to compare with the expected outcomes and determine if the goals of care are being met.

Choice D reason: Reviewing related professional standards of care is important for ensuring quality care, but it is not the direct next step in evaluating the effectiveness of the client's nursing care.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes but does not feel a pulsation. Which action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing an in-service on the Health Insurance Portability and Accountability Act (HIPAA) violations. Which example should the nurse use to demonstrate a HIPAA violation?

Correct Answer is A

Explanation

When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?

Correct Answer is C

Explanation

While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. Which action should the nurse take in response to this finding?

When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium (K+) 3.5 to 5 mEq/L (3.5 to 5 mmol/L)

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

The nurse has removed a barbiturate capsule from the unit dose wrapper to administer to a client. The client decides to watch a television program and requests not to take the medication. Which action should the nurse implement?

The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. While designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?

A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 0 to 10. After placing a call to the healthcare provider, which action should the nurse implement?

The nurse receives a report that a patient with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?