The nurse is completing an assessment on a client following a ...

[ereecah]

The nurse is completing an assessment on a client following a cardiac catheterization procedure. During the initial assessment, the nurse easily palpates the client's right dorsalis pedis and posterior tibial pulses.
 
  The pulses on the client's left leg are strong and easily palpable. During the next assessment, the nurse is unable to palpate or find these pulses on the right side with a Doppler. Which is the priority action by the nurse based on this data?
  1. Notify the healthcare provider immediately.
  2. Assess for the client's right popliteal pulse.
  3. Take the client's blood pressure.
  4. Place the client in Trendelenburg position.

Question 2

While assessing a client with a laceration on the client's left third finger, the nurse notes the presence of inflammation and swelling of the finger. Which other assessment findings might the nurse expect based on this initial data? Select all that apply
 
  1. 1 cm, nontender, soft, left brachial node.
  2. 2 cm, tender, firm, left superior superficial inguinal node.
  3. 2 cm, tender, firm, left epitrochlear node.
  4. 2 cm, nontender, firm, left ulnar node.
  5. 2 cm, tender, firm, left axillary lymph node.

[fraziera112]

Answer to Question 1

Correct Answer: 2
The nurse should attempt to palpate the client's popliteal pulse. This will help the nurse determine how much of this extremity is still receiving oxygenated blood. After the nurse assesses the client's popliteal pulses, it may be appropriate to check the client's vital signs prior to notifying the healthcare provider. The healthcare provider should be notified, but the nurse should be prepared to provide information about the client's condition during their conversation. Trendelenberg can be used to treat a client in shock. The information about the client does not indicate that the client has developed clinical manifestations associated with shock.

Answer to Question 2

Correct Answer: 3, 5
Normally, the epitrochlear nodes are not palpable. A tender, firm, and enlarged node such as this one may indicate the client has an infection. The epitrochlear node drains the forearm and third, fourth, and fifth fingers. The client with an infected wound on the left finger may have a tender enlarged lymph node in the axilla that can be found with light palpation. A lymph node indicative of infection will be greater than 1 cm, tender, and mobile. The left superior superficial inguinal node drains lymph from the client's left leg. The epitrochlear node, not the ulnar node, drains lymph from the ulnar area. Lymph nodes in the arm are the following: subclavicular, central axillary, brachial, and epitrochlear.

[ereecah]

TYSM

[billybob123]

Great answer, keep it coming