The nurse admits a client with a medical diagnosis of peripheral artery disease complaining of severe pain in the right leg. Which is the nurse's priority assessment?
1. Assessing the client's femoral pulses bilaterally
2. Obtaining a thorough nursing history
3. Assessing the client's radial and brachial pulses bilaterally
4. Assessing the femoral, popliteal, posterior tibial, and pedal pulses bilaterally
Correct Answer: 4
This client is at risk for arterial occlusion, and the severe pain in the right leg could be the result of reduced or absent blood flow to the leg. The nurse should assess pulses in both legs immediately, because if the leg is pale, cyanotic, or lacking in pulses, it is a surgical emergency to avoid amputation of the leg. A nursing history would be obtained after assessing the leg and notifying the primary care provider. Assessing only the femoral pulses would not be thorough, because if blood flow is occluded below the femoral pulse, it would be missed. Assessment of pulsation in the arm would be a later priority.
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