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.

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Correct Answer is C

Explanation

Choice A reason: While bowel incontinence is a concern, it does not pose an immediate threat to the client's physiological stability like fluid volume deficit does.

Choice B reason: Impaired bed mobility is important to address for long-term rehabilitation, but it is not the most immediate threat to life.

Choice C reason: Fluid volume deficit, especially due to diarrhea, can lead to dehydration and is a life-threatening condition that requires immediate intervention.

Choice D reason: Caregiver role strain is a significant issue but does not take precedence over the client's immediate physical health needs.

Correct Answer is ["2"]

Explanation

The healthcare provider has prescribed 4,800 mg of magnesium hydroxide. The bottle indicates that each 5 mL contains 400 mg of magnesium hydroxide. We also know that 1 ounce (oz) is equivalent to 30 mL.

Step 1: The amount of magnesium hydroxide the patient needs is 4,800 mg.

Step 2: The concentration of the magnesium hydroxide solution is 400 mg per 5 mL. Step 3: Substitute the values into the formula: 4,800 mg ÷ (400 mg/5 mL).

Step 4: Calculate the volume in mL: 4,800 ÷ (400/5) = 60 mL.

Now, we need to convert this volume from mL to ounces.

Step 5: We know that 1 oz = 30 mL.

Step 6: Substitute the values into the formula: 60 mL ÷ 30 mL/oz.

Step 7: Calculate the volume in oz: 60 ÷ 30 = 2 oz.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?

Correct Answer is C

Explanation

Correct Answer is ["2"]

Explanation

The nurse assesses an adult client with a partial rebreather mask and notes that the oxygen reservoir bag does not deflate completely during respiration and the client's respiratory rate is 14 breaths/minute. Which action should the nurse implement?

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?

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