A nurse is caring for a postoperative client and observes evisceration of the abdominal surgical wound. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take?

Choice A rationale:

Exerting firm pressure when placing the probe (Choice A) is not recommended because it can potentially compress the blood vessels and impede blood flow. This can lead to inaccurate readings and compromise the assessment of the pedal pulses in a client with peripheral vascular disease.

Choice B rationale:

Applying the probe to the exterior aspect of the ankle (Choice B) is not the standard approach for assessing pedal pulses. The pedal pulses are typically assessed on the dorsal (top) and posterior (back) aspects of the foot, as well as the lateral (side) aspects of the ankle. Placing the probe on the exterior aspect of the ankle might not yield accurate results.

Choice C rationale:

Moving the probe until a whooshing sound is present (Choice C) is the correct action when using a Doppler ultrasound stethoscope to assess pedal pulses. The whooshing sound, known as "Doppler sound," indicates the presence of blood flow. The nurse should gently maneuver the probe until this sound is heard, allowing for an accurate assessment of the pulses and blood flow status.

Choice D rationale:

Holding the probe at a 30° angle to the blood vessel (Choice D) is not a standard practice for assessing pedal pulses with a Doppler ultrasound stethoscope. The nurse should place the probe directly over the pulse site and adjust its position until the Doppler sound is detected.

Choice A rationale:

Large pieces of furniture do not necessarily create a significant risk for falls unless they are poorly placed or obstructing pathways. While they can potentially cause accidents, the likelihood of tripping over them is generally lower compared to other hazards.

Choice B rationale:

A bedside table next to the bed is not a significant fall risk factor. In fact, having a bedside table can be beneficial for the client, as it provides a convenient surface for placing items that the client might need during the night.

Choice C rationale:

Raised toilet seats, although they may pose a challenge for individuals with mobility issues, are typically installed to aid those with difficulty sitting down or standing up. They are not a primary risk factor for falls, especially when compared to other more hazardous factors.

Choice D rationale:

Throw rugs on hardwood floors are a significant fall risk factor, especially for older adults or individuals with mobility problems. The rugs can easily shift or bunch up, causing someone to trip and fall. Hardwood floors can also become slippery, and the combination of a throw rug on such a surface increases the risk of accidents. The rationale behind this choice is grounded in the potential for tripping and slipping hazards that these throw rugs can introduce, especially in individuals who might already have balance or mobility issues.