On the diagram provided, place an X where the nurse would assess ...

[LaDunn]

On the diagram provided, place an X where the nurse would assess the apical pulse in an adult. (Figure 29-14)
 
  What will be an ideal response?

Question 2

The RN assesses a client who is recovering from femoral popliteal bypass surgery and discovers that it is difficult to assess the dorsalis pedis pulses. Which of the following nursing interventions would be most appropriate for the nurse to use?
 
  1. Ask another nurse to assess the pulses.
  2. Document the findings.
  3. Obtain a Doppler ultrasound stethoscope.
  4. Wait and just try again later.

[mirabriestensky]

Answer to Question 1

Correct Answer:
Rationale : The apical is at the apex of the heart. In an adult, this is located on the left side of the chest, about 8 cm (3 in) to the left of the sternum at the fifth intercostal space.

Answer to Question 2

Correct Answer: 3
Rationale 1: If one nurse is having difficulty with the pulse and accuracy, getting another nurse is not going to be the best choice.
Rationale 2: Just documenting the findings does not address the problem of getting an accurate pulse reading.
Rationale 3: Obtaining a Doppler ultrasound stethoscope is the appropriate action to take. The Doppler will ensure accuracy by helping to exclude environmental sounds.
Rationale 4: Waiting until later may be harmful to the client, creating an unsafe environment.

[LaDunn]

Thank you!

[mirabriestensky]

Always glad to help...