The nurse begins morning assessment on a male client and notices that she is unable to palpate either of his dorsalis pedis pulses in his feet. What is the first nursing action after assessing this…

Question

Options

• APalpate these pulses again in 15 minutes.
• BUse a Doppler to determine presence and strength of these pulses.
• CDocument the finding that the pulses are not palpable.
• DCall the physician and notify the physician of this finding.

• A
  5% (2)
• B
  82% (32)
• C
  10% (4)
• D
  3% (1)

Explanation

(A) Palpating these pulses again in 15 minutes may only result in the same findings. (B) Any time during an assessment that the nurse is unable to palpate pulses, the nurse should then obtain a Doppler and assess for presence or absence of the pulse and pulse strength, if a pulse ispresent. (C) Pulses may be present and assessed through use of a Doppler. Absence of palpable pulses does not indicate absence of blood flow unless pulses cannot be located with a Doppler. (D) The nurse would only call the physician after determining that the pulses are absent by both palpation and Doppler.

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