Practice Question
The nurse palpates the client's dorsalis pedis and posterior tibial pulses in the right lower extremity and determines that they cannot be felt. What is the priority nursing action?
Answer Choices:
Correct Answer:
Assess the dorsalis pedis and posterior tibial using a Doppler.
Rationale:
🟦 When pulses are not palpable, using a Doppler is the proper next step to check for actual blood flow.
🟦 Doppler devices are more sensitive than fingers and can detect weak arterial pulses that are not easily felt.
🟦 Confirming whether pulses are truly absent or just faint guides decisions about possible ischemia or arterial occlusion.
🟦 Accurate assessment with a Doppler allows for appropriate provider notification and further diagnostic testing if needed.
🟦 Documenting or escalating care without Doppler verification risks mislabeling perfusion status of the limb.
Ask a colleague to palpate the areas and document the colleague's findings.
🟦 Having a colleague palpate does not increase sensitivity like a Doppler does, so weak pulses may still be missed.
🟦 This step focuses on subjective confirmation instead of using an objective tool to truly detect arterial flow.
Place a warm towel on the client's foot to promote vasodilation.
🟦 Warmth may slightly improve superficial circulation, but it does not directly answer whether arterial pulses are present.
🟦 Applying heat first can delay critical assessment in a situation where ischemia or arterial obstruction must be ruled out quickly.
Document the finding in the client's chart.
🟦 Documenting “no pulses” without Doppler confirmation is incomplete, because the pulses may be weak but present.
🟦 Accurate charting requires using all appropriate assessment tools, including a Doppler, before labeling pulses as absent.
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This question is from W6 NR304 CJE Health Assessment Open Check 2561 which contains 42 questions.
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From Exam
W6 NR304 CJE Health Assessment Open Check 2561
42 Questions
View Full Exam Start PracticingQuestion Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Health Assessment
- Answer Choices: 4