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 of the following would be the most appropriate action for the nurse at this time? 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.
2
Rationale 1: The nurse should attempt to palpate the client's popliteal pulse. The healthcare provider should be notified, but the nurse should be prepared to provide information about the client's popliteal pulse during their conversation.
Rationale 2: This is the appropriate action at this time. This will help the nurse determine how much of this extremity is still receiving oxygenated blood.
Rationale 3: 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.
Rationale 4: 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.
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