The nurse is assessing a client's peripheral pulses. The nurse palpates the top portion of the client's foot. The right pulse is easily palpable, and the left pulse is diminished but still palpable. How should the nurse document these findings?
A)Bilateral dorsalis pedis (DP) pulses palpable. Right DP 2+, left DP 1+.
B)Bilateral DP pulses palpable. Right DP 3+, left DP 2+.
C)Bilateral popliteal pulses palpable. Right foot left foot.
D)Bilateral posterior tibial (PT) pulses palpable. Right PT 2+, left PT 1+.

Question

The nurse is assessing a client's peripheral pulses.  The nurse palpates the top portion of the client's foot.  The right pulse is easily palpable, and the left pulse is diminished but still palpable.  How should the nurse document these findings?
A)Bilateral dorsalis pedis (DP) pulses palpable.  Right DP 2+, left DP 1+.
B)Bilateral DP pulses palpable.  Right DP 3+, left DP 2+.
C)Bilateral popliteal pulses palpable.  Right foot > left foot.
D)Bilateral posterior tibial (PT) pulses palpable.  Right PT 2+, left PT 1+.

Quizplus · Accepted Answer

11ecbb05_cb75_5e6b_b433_6b00a6418a26_MD0009_00 The DP pulse is located on the top or dorsal part of the foot. The nurse should compare the characteristics of the arteries on the right and left extremities simultaneously to determine symmetry. The force of the pulse should be rated on the following scale. 11ecbb05_cb75_5e6c_b433_af21181061e0_MD0009_00 (Option B) DP is the correct artery being assessed, but 3+ would indicate a full, bounding pulse and 2+ would indicate a normal pulse. (Option C) The popliteal pulse is assessed just behind the knee area, not on the foot. The description of the right foot being greater than the left foot does not indicate the force of the individual pulse. (Option D) Posterior tibial pulses are palpated just behind the medial malleolus bone on the foot. The description of 2+ and 1+ is accurate. Educational objective: The nurse should palpate and compare the characteristic and quality of the pulses on the right and left extremities simultaneously to determine symmetry. The force of the pulse should be rated as 0, absent; 1+, weak; 2+, normal; and 3+, increased, full, bounding. These descriptions should be documented in the client's record.

The Nurse Is Assessing a Client's Peripheral Pulses