The nurse is assessing the client's peripheral pulse, and is not ...

[lracut11]

The nurse is assessing the client's peripheral pulse, and is not able to palpate a pedal pulse. The client's foot is pink and warm. Which action by the nurse is the most appropriate?
 
  1. Apply a warm soak to the foot.
  2. Notify the health care provider that the client has lost circulation to the foot.
  3. Elevate the foot.
  4. Auscultate the pulse using an ultrasound Doppler.

Question 2

The nurse is assessing the client's peripheral pulses. What would the nurse assess for? Select all that apply.
 
  1. Bilaterality
  2. Regularity
  3. Strength
  4. Rate
  5. Arrhythmia

[SamMuagrove]

Answer to Question 1

Correct Answer: 4

If the pulse is not palpable, the nurse would attempt to auscultate using a Doppler. The nurse would not apply a warm soak, because there is the potential for reduced sensation if pulses are not palpable, which could result in a burn. There is no need to notify the health care provider, and elevating the foot would reduce blood flow, making the pulse more difficult to palpate.

Answer to Question 2

Correct Answer: 1,2,3,4
When assessing peripheral pulses, the nurse assesses for bilaterality, regularity, strength, and rate. The nurse could not determine if there were an arrhythmia without the use of an ECG.