A nurse is caring for a group of clients. The nurse should obtain a blood pressure reading using only the left extremity from which of the following clients?
A client who has a peripherally inserted central catheter (PICC) in the left arm
A client who has a right upper extremity arteriovenous fistula
A client who has right-sided weakness due to Parkinson's disease
A client who has left-sided Bell's palsy
The Correct Answer is B
The nurse should obtain a blood pressure reading using only the left extremity from a client who has a right upper extremity arteriovenous fistula. An arteriovenous fistula is a surgical connection between an artery and a vein that is created for hemodialysis access.
Measuring blood pressure on the arm with an arteriovenous fistula can cause damage to the fistula, reduce blood flow, and increase the risk of infection or thrombosis. Therefore, blood pressure should be measured on the opposite arm or on another site such as the leg.
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Related Questions
Correct Answer is ["A","B","C"]
Explanation
Drinking plenty of fluids helps flush out bacteria from the urinary tract and prevent urinary stasis . Wiping from front to back prevents contamination of the urethra with fecal bacteria . Cranberry juice may prevent bacterial adherence to the bladder wall and lower the pH of urine, making it less favorable for bacterial growth . However, cranberry juice should be low in fructose because high-fructose corn syrup may increase bacterial growth . Bubble baths may irritate the urethra and increase the risk of infection . Voiding frequently (every 2 to 3 hours) prevents urinary stasis and bacterial growth .
Correct Answer is D
Explanation
The nurse should attend to the client who has thrombocytopenia and reports a nosebleed first, as this client has the most urgent problem and is at risk of hemorrhage. Thrombocytopenia is a condition characterized by a low platelet count, which impairs blood clotting and increases bleeding tendencies. The other clients have chronic or stable conditions that require ongoing monitoring and intervention, but are not as urgent as the client with the nosebleed.
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