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

Answer and Explanation

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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Correct Answer is B

Explanation

This indicates hyperkalemia, which is a common complication of severe burn injuries due to massive cell destruction and fluid lossfrom damaged tissues. Hyperkalemia can lead to cardiac dysrhythmias and arrest, which are signs of hypovolemic shock.

A. Place the client in a protective environment. B. Clean surfaces with chlorhexidine. C. Wash hands with alcohol-based hand rub. D. Obtain a stool specimen with gloves.

Correct Answer is A

Explanation

Clostridium difficile is a spore-forming bacteria that can cause severe diarrhea and other gastrointestinal symptoms. It's highly contagious and can easily spread to other patients.Alcohol-based hand rubs are not effective against spores and should not be used for hand hygiene in this case. Chlorhexidine is also not sporicidal and should not be used for environmental cleaning. A protective environment is indicated for clients who are at risk of infection from others, not for clients who are infectious to others.Gloves are important for preventing the spread of infection, but they should be used in conjunction with other infection control measures, such as handwashing and protective isolation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a severe burn injury. The nurse should recognize which of the following client findings as an indication of hypovolemic shock?

Correct Answer is B

Explanation

A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has toxoplasmosis and is HIV positive. Which of the following questions should the nurse ask to gather data about toxoplasmosis?

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