A nurse is using a Doppler ultrasound stethoscope to assess the pedal pulses of a client who has peripheral vascular disease. Which of the following actions should the nurse plan to take?
Exert firm pressure when placing the probe.
Apply the probe to the exterior aspect of the ankle.
Move the probe until a whooshing sound is present.
Hold the probe at a 30° angle to the blood vessel.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
During bladder irrigation, the nurse should instill a specific volume of the prescribed irrigation solution into the bladder to facilitate the removal of clots, mucus, or other debris from the urinary catheter and bladder. The recommended volume to instill is usually 400 to 500 mL, which helps to effectively flush out the bladder without overdistending it.
Choice B rationale:
Clamping the drainage tubing distal to the injection port during bladder irrigation is incorrect. The drainage tubing should remain unclamped to allow the irrigation solution to flow into the bladder and facilitate the removal of debris. Clamping the tubing would prevent the solution from entering the bladder and hinder the irrigation process.
Choice C rationale:
Using a syringe with a 19-gauge needle is not relevant to the process of bladder irrigation. Bladder irrigation is typically performed using a specific irrigation kit that includes appropriate tubing and components, not a syringe and needle.
Choice D rationale:
Withdrawing the irrigation solution into the syringe is not a standard procedure during bladder irrigation. The purpose of bladder irrigation is to instill a specific volume of solution into the bladder and then allow it to drain out, flushing the bladder in the process. Drawing the solution back into a syringe after instillation would disrupt the intended irrigation process.
Correct Answer is C
Explanation
The correct answer is C.
Choice A reason: Walking on the client’s right side is incorrect because the nurse should walk on the client’s left side. This is the weaker side and the side where support is most needed.
Choice B reason: Instructing the client to look down at their feet when ambulating is incorrect because the client should be instructed to look straight ahead, not down at their feet, to maintain balance and prevent falls.
Choice C reason: Have the client sit on the side of the bed for at least 60 seconds before ambulating. This allows the nurse to assess the client’s tolerance and readiness for ambulation, and it helps prevent dizziness or fainting due to orthostatic hypotension.
Choice D reason: Placing the gait belt securely around the client’s lower chest is incorrect because the gait belt should be placed around the client’s waist, not the lower chest. This provides a secure grip for the nurse and allows for safer ambulation.
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