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 B

Explanation

Choice A reason: Thyroidectomy is a surgical procedure that involves the removal of all or part of the thyroid gland. While there are risks associated with any surgery, thyroidectomy is not typically associated with fat embolism syndrome (FES). FES is more commonly linked to orthopedic procedures and trauma, particularly those involving long bones.

Choice B reason: Internal fixation of a fractured hip is a procedure that carries a risk for developing FES. FES is a serious and potentially life-threatening condition that occurs when fat globules enter the bloodstream and lodge within the blood vessels of the lungs or other organs. Hip fractures, especially those involving the long bones, can result in the release of fat globules into the bloodstream during the surgical repair process. Early surgical fixation is thought to reduce the risk of FES.

Choice C reason: Repair of a torn rotator cuff involves the shoulder joint and, while it is a significant surgical procedure, it is not typically associated with a high risk of FES. The rotator cuff is composed of muscles and tendons, and its repair does not usually involve manipulation of the long bones where fat embolism is more likely to occur.

Choice D reason: Tympanoplasty is a surgical procedure to repair a hole in the eardrum. It is an otologic procedure that does not involve the long bones or orthopedic manipulation. Therefore, it is not associated with a risk of developing FES.

A. Change the transparent membrane dressing daily. B. Access the catheter using a non-coring needle. C. Maintain a continuous IV infusion through the PICC line. D. Flush the catheter with a 0.9% sodium chloride solution after each use.

Correct Answer is D

Explanation

Choice A reason : Changing the transparent membrane dressing daily is not necessary unless it's soiled or compromised. The dressing is typically changed every 7 days or per institutional policy to reduce the risk of infection.

Choice B reason: Using a non-coring needle is not applicable for PICC lines as they are designed for use with a luer-lock syringe for medication administration and flushing.

Choice C reason : Maintaining a continuous IV infusion is not required for a PICC line unless clinically indicated. Intermittent use is common for medication administration, and the line should be flushed before and after use to maintain patency.

Choice D reason : Flushing the catheter with a 0.9% sodium chloride solution after each use is the correct action. This helps to maintain catheter patency and prevent occlusion.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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