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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason : A severe, throbbing headache is a common and significant manifestation of autonomic dysreflexia. This condition is a potentially life-threatening medical emergency that can occur in individuals with spinal cord injuries, typically above the T6 level. The headache results from a sudden and severe increase in blood pressure due to an exaggerated response of the autonomic nervous system to a stimulus below the level of the injury.

Choice B reason: Hypotension, or low blood pressure, is not a manifestation of autonomic dysreflexia. In fact, the condition is characterized by hypertension, or high blood pressure, which is a critical sign that requires immediate attention to prevent complications such as stroke or seizure.

Choice C reason: Fever is not a direct manifestation of autonomic dysreflexia. While a fever may indicate an infection or other systemic issue, autonomic dysreflexia itself is specifically associated with a rapid onset of high blood pressure and other autonomic disturbances.

Choice D reason: Cyanosis of the head and neck, which refers to a bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood, is not a typical manifestation of autonomic dysreflexia. The condition primarily causes hypertension and its associated symptoms, rather than issues with oxygenation.

Correct Answer is ["8.3"]

Explanation

Step 1: Total volume = 1000 mL (which is 1 liter)

Step 2: Total time = 2 hours. But since the infusion pump rate is typically set in mL per minute, we need to convert this to minutes. There are 60 minutes in an hour, so 2 hours is 2 × 60 = 120 minutes.

Step 3: Now we can calculate the rate. The rate is the total volume divided by the total time. So, the rate = 1000 mL ÷ 120 minutes.

Calculating the above gives us the rate at which the nurse will set the infusion pump. Let's calculate it:

Step 4: Rate = 1000 mL ÷ 120 minutes = 8.33 mL/minute.

So, the nurse will set the infusion pump at a rate of approximately 8.33 mL per minute. If rounding is required, this can be rounded to 8.3 mL per minute.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a spinal cord injury is at risk for experiencing autonomic dysreflexia. The nurse would carefully monitor the client for which of the following manifestations?

Correct Answer is A

Explanation

The nurse is preparing to administer 1 liter (1000 mL) of 0.9% NS over 2 hours intravenously to a patient experiencing shock. At what rate will the nurse set the infusion pump? Enter the number only.

Correct Answer is ["8.3"]

Explanation

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