While completing an admission assessment, the nurse is unable to palpate the client's left dorsalis pedis (DP) pulse. Which intervention is most important for the nurse to implement?

Use a doppler to assess an audible DP pulse.

Place a mark where DP pulse is auscultated.

Review client's history for vascular disease.

Assess capillary refill distal to the DP pulse.

Answer and Explanation

The Correct Answer is A

A) Use a doppler to assess an audible DP pulse:
Using a doppler to assess an audible DP pulse may provide additional information about the presence or absence of the pulse, but it does not address the underlying cause of the absent pulse. It is important to first investigate potential causes, such as vascular disease, before resorting to additional assessment techniques.

B) Place a mark where DP pulse is auscultated:
Marking the location where the DP pulse is auscultated may assist with future assessments but does not address the underlying reason for the absent pulse. It is essential to determine the cause of the absent pulse before considering further interventions.

C) Review client's history for vascular disease:
Reviewing the client's history for vascular disease is the most important intervention in this scenario. Absence of a DP pulse may indicate peripheral vascular disease or other circulatory issues. Reviewing the client's history for risk factors such as diabetes, hypertension, smoking, or previous vascular problems can provide valuable information to guide further assessment and management.

D) Assess capillary refill distal to the DP pulse:
Assessing capillary refill distal to the DP pulse is important for evaluating peripheral perfusion but may not directly address the underlying cause of the absent pulse. While assessing capillary refill is a valuable assessment, reviewing the client's history for vascular disease takes precedence in determining the cause of the absent DP pulse.

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Correct Answer is D

Explanation

A) A 2-year-old who is demonstrating diaphragmatic breathing:
In young children, especially infants and toddlers, the PMI is typically easier to locate due to their smaller size and thinner chest wall. Diaphragmatic breathing, which is normal in infants and toddlers, does not necessarily interfere with locating the PMI.

B) A 45-year-old long distance runner with a body mass index (BMI) of 18 kg/m2:
A BMI within the normal range does not necessarily affect the ability to locate the PMI. Additionally, physical fitness, such as being a long-distance runner, may contribute to better cardiovascular health and clearer identification of the PMI.

C) A 75-year-old with a pneumothorax and a chest tube:
In clients with a pneumothorax and a chest tube, the presence of medical devices and underlying respiratory conditions may affect the ability to locate the PMI. However, the primary challenge here would likely be due to the presence of the chest tube rather than the client's age alone.

D) A 54-year-old who is 5 feet (152.4 cm) tall and weighs 300 pounds (136.1 kg):
In individuals who are significantly overweight or obese, locating the PMI may be challenging due to increased chest wall thickness and adipose tissue. The increased depth of tissue can make palpating the PMI more difficult, leading to anticipated difficulty in locating it accurately.

A. Suggest that the client schedule a mammogram after her next menstrual period. B. Explain to the client that an ultrasound of the breast will likely be necessary. C. Assure the client that her breasts are normal, and advise annual evaluations. D. Request a return visit after her menstrual period for a breast exam re-check.

Correct Answer is C

Explanation

Answer: C. Assure the client that her breasts are normal, and advise annual evaluations.

Rationale:

A. Suggest that the client schedule a mammogram after her next menstrual period:
A mammogram is generally not indicated for adolescents unless there are specific concerns such as a family history of breast cancer or the presence of abnormal findings. Given the client's age and the findings of generalized lumpiness without discrete masses, a mammogram would not be the most appropriate action at this stage.

B. Explain to the client that an ultrasound of the breast will likely be necessary:
An ultrasound is typically used for further evaluation if discrete masses are found or if there are unusual characteristics in the breast tissue. In this case, the generalized lumpiness is likely related to normal physiological changes, making an ultrasound unnecessary at this time.

C. Assure the client that her breasts are normal, and advise annual evaluations:
The findings of generalized lumpiness and tenderness before menstruation are consistent with normal physiological changes associated with the menstrual cycle, often due to hormonal fluctuations. Providing reassurance and advising annual evaluations is appropriate, as it addresses the client's concerns and promotes confidence in her breast health without unnecessary interventions.

D. Request a return visit after her menstrual period for a breast exam re-check:
While a follow-up can be beneficial, it may not be necessary in this case since the findings are typical of normal breast tissue changes associated with the menstrual cycle. Reassuring the client and encouraging annual evaluations is a more effective approach than suggesting an unnecessary follow-up visit.

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While completing an admission assessment, the nurse is unable to palpate the client's left dorsalis pedis (DP) pulse. Which intervention is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

Rationale:

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