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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A history of inflammatory bowel disease, such as Crohn's disease or ulcerative colitis, is a risk factor for colorectal cancer . These conditions cause chronic inflammation and damage to the cells lining the colon and rectum, which may increase the likelihood of DNA mutations and cancer development. A diet high in fiber may help lower the risk of colorectal cancer by promoting regular bowel movements and reducing exposure to toxins. Age 46 years is not a significant risk factor, as most cases of colorectal cancer occur in people older than 50. BMI of 24 is within the normal range and does not indicate obesity, which is another risk factor for colorectal cancer.
Correct Answer is C
Explanation
Altered level of consciousness (LOC) is the earliest and most sensitive indicator of increased ICP, which can result from brain injury, tumor, hemorrhage, infection, or edema.
The nurse should monitor the client's LOC using the Glasgow Coma Scale (GCS) and report any changes or deterioration to the provider. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs of increased ICP that indicate brainstem compression and herniation, which are life-threatening emergencies.
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