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

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.

A. Place both feet apart and shift from the back to the front leg when moving the client up in bed. B. Position the client's arms at their sides prior to moving them up in bed. C. Elevate the head of the client's bed 30° prior to moving the client. D. Bend at the waist when grasping the draw sheet when moving the client up in bed.

Correct Answer is A

Explanation

Choice A rationale:

This choice reflects the correct technique for maintaining balance and using proper body mechanics when assisting with moving a client up in bed. Shifting weight from the back to the front leg while keeping the feet apart provides a stable base and reduces the risk of injury to the nurse.

Choice B rationale:

Positioning the client's arms at their sides before moving them up in bed is not a necessary step and may not contribute significantly to the process. The primary focus should be on proper body mechanics and the use of assistive devices, such as a draw sheet, to ensure safe patient handling.

Choice C rationale:

Elevating the head of the client's bed 30° is not directly related to the task of moving the client up in bed using a draw sheet. While head elevation might have other clinical indications, it does not impact the technique of assisting with repositioning.

Choice D rationale:

Bending at the waist when grasping the draw sheet is incorrect body mechanics and can lead to strain on the nurse's back. Proper technique involves using the legs to bend and lift while keeping the back straight, reducing the risk of injury.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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