While assessing the dorsalis pedis pulse of a client, the nurse determ

While assessing the dorsalis pedis pulse of a client, the nurse determines that the pulse is absent. However, the extremity is warm and pink with nail beds blanching at 2 to 3 seconds of capillary refilling time.

How would the nurse explain these findings?
1. A change in the client’s health status has occurred.
2. The client has thrown a blood clot in that extremity.
3. The RN’s watch has stopped working.
4. Too much pressure was applied over the pulse site.

ANSWER

Correct Answer: 4
Rationale 1: The information provided gives no indication that any health change has occurred.
Rationale 2: The assessment data given (warm, pink, etc.) are not symptoms of a blood clot.
Rationale 3: There is no data given in regard to equipment malfunction, such as the nurse’s watch.
Rationale 4: Too firm of pressure on a pulse site will obliterate that pulse because assessing the dorsalis pedis pulse requires one to apply some pressure over the dorsalis pedis artery, making contact with the cones in the foot.