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 C

Explanation

Referred pain is pain that is felt in a location different from its source due to shared nerve pathways or central nervous system processing. A client who has pancreatitis may experience pain in the left shoulder due to irritation of the diaphragm by pancreatic enzymes or inflammation. This pain is referred from the abdominal cavity to the shoulder through the phrenic nerve.

A client who has peritonitis reports generalized abdominal pain that corresponds to the site of inflammation and infection in the peritoneum. A client who has angina reports substernal chest pain that reflects the ischemia and hypoxia of the myocardium. A client who is postoperative reports incisional pain that is caused by tissue damage and inflammation at the surgical site.

A. Initiate venous access with a 21-gauge needle. B. Use Y tubing with 0.9% sodium chloride when administering the transfusion. C. Administer the unit of packed RBCs over 1 hr. D. Obtain the client's first set of vital signs 1 hr after initiating the transfusion.

Correct Answer is A

Explanation

Practice standards indicateblood should be infused through a 20-gauge or larger catheter to prevent hemolysis [destruction] of red blood cells. Y tubing with 0.9% sodium chloride is used to administer blood products is not necessary.A unit of packed RBCs should be administered over 2 to 4 hours, unless otherwise ordered by the provider, to reduce the risk of fluid overload and transfusion reactions . The client's vital signs should be obtained before, during (15 minutes after starting and every hour thereafter), and after the transfusion to monitor for any signs of adverse reactions.

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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 assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?

Correct Answer is C

Explanation

A nurse is preparing to administer a unit of packed RBCS to a client. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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