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 C

Explanation

Choice A reason: Decreased urinary output is not a direct indicator of morphine's effectiveness in acute heart failure. While morphine can lead to urinary retention, this is generally considered a side effect rather than an intended therapeutic outcome.

Choice B reason: Emesis, or vomiting, of 250 mL is not an indication of morphine's effectiveness. In fact, nausea and vomiting are common side effects of morphine and other opioids. If emesis occurs, it may necessitate further intervention.

Choice C reason: Decreased anxiety is a sign that the morphine is effective. Morphine has anxiolytic properties, meaning it can help alleviate anxiety, which is beneficial in acute heart failure where anxiety can exacerbate symptoms like shortness of breath.

Choice D reason: An increased respiratory rate to 26/min is not an indication of morphine's effectiveness and is a cause for concern. Morphine can depress the respiratory system, and an increased respiratory rate may indicate compensation for hypoxemia or the onset of adverse effects.

A. "Do you feel like you have food stuck at the base of your throat?" B. "Do you feel any burning sensations in your throat?" C. "Do you have any feelings of fullness in the neck?" D. "Do you have any problems with pain while swallowing?"

Correct Answer is A

Explanation

Choice A reason: Asking if the client feels like they have food stuck at the base of their throat is a pertinent question for assessing swallowing in a client with oral achalasia. Achalasia is characterized by difficulty in swallowing due to the inability of the lower esophageal sphincter to relax, leading to a sensation of food being stuck.

Choice B reason: While burning sensations in the throat can be associated with gastroesophageal reflux disease (GERD), they are not specific to achalasia. However, some clients with achalasia may experience similar symptoms due to food stasis and fermentation in the esophagus.

Choice C reason: Feelings of fullness in the neck are not a typical symptom of achalasia. Achalasia primarily affects the esophagus and does not usually cause a sensation of fullness in the neck.

Choice D reason: Pain while swallowing, or odynophagia, can occur in achalasia but is more commonly associated with conditions that cause inflammation or irritation of the esophagus, such as infections or ingestion of irritants.

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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 nurse is caring for a client who has acute heart failure and received morphine intravenously 30 minutes ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

Correct Answer is C

Explanation

A nurse is caring for a client who has oral achalasia. The nurse should ask the client which of the following questions to assess their ability to swallow?

Correct Answer is A

Explanation

A patient is exhibiting an altered level of consciousness and is unresponsive to verbal stimuli. To elicit a response from a painful stimulus, the nurse would:

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