The nurse is unable to palpate a client's pedal pulse even though the 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.
4
Rationale 1: 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.
Rationale 2: There is no need to notify the health care provider.
Rationale 3: Elevating the foot would reduce blood flow, making the pulse more difficult to palpate.
Rationale 4: If the pulse is not palpable, the nurse would attempt to auscultate using a Doppler.
Global Rationale: 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.
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