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: Anticonvulsants are medications used to prevent seizures. While seizures can occur after a stroke, anticonvulsants are not routinely prescribed unless the patient has a history of seizures or has experienced seizures post-stroke. Therefore, anticonvulsants would not be the standard pharmacologic therapy for all patients being discharged after an ischemic stroke.

Choice B reason: Diuretics are used to remove excess fluid from the body and are commonly prescribed for conditions such as heart failure or high blood pressure. They are not typically used as a standard treatment for ischemic stroke unless the patient has a specific condition that requires fluid management.

Choice C reason: Antithrombotic agents, such as aspirin or clopidogrel, are commonly prescribed to patients after an ischemic stroke to prevent further clot formation and reduce the risk of recurrent strokes. These medications work by inhibiting platelet aggregation and are a key part of secondary prevention in stroke management.

Choice D reason: Opioid analgesics are strong painkillers that are used to treat severe pain. They are not typically prescribed upon discharge for ischemic stroke patients unless there is a specific indication for pain management that cannot be managed with other medications.

A. 150 mL of serosanguineous drainage B. 75 mL of greenish-yellow drainage C. 100 mL of red drainage D. 200 mL of brown drainage

Correct Answer is C

Explanation

Choice A reason: Serosanguineous drainage, which is a mixture of blood and a clear yellow liquid known as serum, is generally expected after surgery. While the amount of 150 mL may seem significant, it is not uncommon in the first hour postoperatively, especially after abdominal surgery. The nurse should continue to monitor the drainage and report if the volume increases significantly or if the drainage becomes bright red, indicating active bleeding.

Choice B reason: Greenish-yellow drainage is typically bile, which can be present in NG tube drainage after abdominal surgery. This type of drainage is not unusual and does not necessarily need to be reported unless accompanied by other concerning symptoms or changes in the patient's condition.

Choice C reason: 100 mL of red drainage is concerning and should be reported to the provider immediately. Red drainage suggests active bleeding, and in the context of the first postoperative hour, it could indicate a complication such as hemorrhage. Prompt assessment and intervention are required to address this potential emergency situation.

Choice D reason: Brown drainage may be old blood or could be related to the contents of the gastrointestinal tract. While 200 mL is a larger volume, brown drainage is not typically as concerning as bright red drainage. However, the nurse should monitor for changes in the color and consistency of the drainage, as well as the patient's vital signs and overall status.

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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

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Correct Answer is C

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