A nurse is caring for a group of clients. From which of the following clients should the nurse obtain a blood pressure reading using only the left extremity?
A client who has a peripherally inserted central catheter (PICC) in the left arm
A client who has left-sided Bell's palsy
A client who has right-sided weakness due to Parkinson's disease
A client who has a right upper extremity arteriovenous fistula
The Correct Answer is D
Choice A reason: While it is generally advised to avoid taking blood pressure readings from an arm with a PICC line to prevent complications, if the right arm cannot be used, as may be the case with the other clients listed, the nurse may have to use the left arm with extreme caution, ensuring not to disrupt the PICC line.
Choice B reason: Bell's palsy affects facial nerves and does not typically impact the measurement of blood pressure. Therefore, there is no contraindication to using the left arm for a blood pressure reading in a client with left-sided Bell's palsy.
Choice C reason: A client with right-sided weakness due to Parkinson's disease can have their blood pressure taken on the left side if the right side is too weak to provide an accurate reading or if using the right side would cause discomfort to the client.
Choice D reason: For a client with a right upper extremity arteriovenous fistula, typically created for dialysis access, blood pressure measurements should not be taken on that arm to avoid damaging the fistula. Therefore, the left arm should be used for blood pressure readings in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Pressing down on the orbital area of the eye is not a recommended method for eliciting a pain response due to the risk of causing injury to the eye.
Choice B reason: Pinching the trapezius muscle is a common and safe method to elicit a pain response in an unresponsive patient. It is less invasive and carries a lower risk of injury compared to other methods.
Choice C reason: Using a 25-gauge needle is not a standard practice for eliciting a pain response due to the risk of puncture and infection.
Choice D reason: Eliciting a reflex with a reflex hammer is used to assess neurological function, not to elicit a pain response in an unresponsive patient.
Correct Answer is B
Explanation
Choice A reason: This statement does not indicate a need for further instruction. It is recommended to take other medications at least 30 minutes after alendronate to ensure proper absorption of the drug.
Choice B reason: This statement indicates a need for further instruction. Alendronate should be taken with plain water, not milk. The calcium in milk can interfere with the absorption of alendronate.
Choice C reason: This statement is correct and does not indicate a need for further instruction. Patients are advised to stay upright for at least 30 minutes after taking alendronate to prevent esophageal irritation or reflux.
Choice D reason: This statement is correct and does not indicate a need for further instruction. Periodic bone density tests are necessary to monitor the effectiveness of alendronate therapy in treating osteoporosis.
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