HESI RN Health Assessment Proctored Exam
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?
Explanation & Rationale
Choice A rationale Placing a mark where the DP pulse is auscultated can help in future assessments but does not address the immediate need to locate the pulse. Choice B rationale Using a Doppler to assess an audible DP pulse is the correct answer. A Doppler ultrasound device is helpful when it is impossible or difficult to assess a pulse or when pulses are not palpable. Choice C rationale Assessing capillary refill distal to the DP pulse is important but should be done after attempting to locate the pulse with a Doppler. Choice D rationale Reviewing the client’s history for vascular disease is essential for understanding the underlying cause but does not address the immediate need to locate the pulse.
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