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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Slip-on rubber shower shoes are not recommended as they do not provide the necessary support or stability for a client with weakness on one side.
Choice B reason: Tennis shoes with Velcro are ideal as they offer good support and are easy to fasten, which is beneficial for a client with one-sided weakness and potentially limited dexterity.
Choice C reason: Leather-soled loafers can be slippery and do not offer the snug fit and support needed for safe ambulation post-stroke.
Choice D reason: Rubber-soled slippers may provide some grip but typically do not offer the structured support that is necessary for a client with post-stroke weakness.
Correct Answer is A
Explanation
Choice A reason: The presence of soft, formed, and light brown feces is normal and does not preclude testing for occult blood. The nurse should proceed with obtaining the specimen as ordered.
Choice B reason: There is no need to contact the healthcare provider before obtaining the specimen if the stool appears normal and the test for occult blood has been ordered.
Choice C reason: Waiting for observable blood is not necessary for an occult blood test, which is designed to detect blood that is not visible to the naked eye.
Choice D reason: Withholding specimen collection until tarry black stool is observed is not indicated. Tarry black stool can indicate bleeding in the upper gastrointestinal tract, but the test for occult blood is used to detect blood that may not be visible in the stool. Bolded text indicates the correct answers and important information.
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