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

The nurse should consult the client before approaching the dog, as the service animal is working and may have specific instructions from the handler on how to interact with others. The nurse should respect the client's autonomy and preferences regarding their service animal and not interfere with their bond or function.

A. WBC count 8,400/mm3 B. Reports pain of 4 on a scale from 0 to 10 when coughing C. Serosanguineous exudate noted on dressing change D. Hemoglobin 10 mg/dL

Correct Answer is D

Explanation

This is a low hemoglobin level, which may indicate blood loss. The nurse should report this finding to the provider immediately, as it may require further investigation and intervention, such as blood transfusion.

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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

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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