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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Verifying placement of a nasogastric tube requires specialized training and knowledge to ensure correct placement and prevent complications. The nurse should retain this task to ensure patient safety.

Choice B rationale:

Evaluating a client's understanding of how to use crutches involves assessing the client's comprehension and ability to use crutches safely and effectively. This task requires nursing judgment and should not be delegated to an assistive personnel.

Choice C rationale:

Replacing the gauze on a skin abrasion is a task that can be safely assigned to an assistive personnel. It involves basic wound care, which typically falls within the scope of practice for assistive personnel. The AP can be trained to follow established protocols for wound cleaning and dressing changes.

Choice D rationale:

Monitoring bowel sounds requires clinical judgment and the ability to recognize variations from the normal range. The nurse should perform this task, as it involves assessing the client's condition and making appropriate decisions based on the findings.

A. "I should breathe normally while I am performing this relaxation technique.". B. "I should imagine myself in a peaceful, garden-like setting as I begin.". C. "I'll compare the sensations I feel when I tense my muscles to what I feel when I relax them.". D. "I'll use a series of stretches when I practice this technique.".

Correct Answer is C

Explanation

The correct answer is choiceC. “I’ll compare the sensations I feel when I tense my muscles to what I feel when I relax them.”

Choice A rationale:While breathing normally is important during relaxation techniques, progressive muscle relaxation specifically focuses on tensing and relaxing muscle groups to recognize the difference in sensations.

Choice B rationale:Imagining a peaceful setting is more related to guided imagery or visualization techniques, not progressive muscle relaxation.

Choice C rationale:This is correct because progressive muscle relaxation involves tensing and then relaxing muscle groups to help the individual recognize the difference between tension and relaxation.

Choice D rationale:Using a series of stretches is not a part of progressive muscle relaxation; it is more related to stretching exercises or yoga.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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