A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients.
The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients?
A client who had blood drawn from the right antecubital area 1 hr ago.
A client who has a right peripherally inserted central catheter.
A client who had dialysis and is using an arteriovenous shunt in the left lower forearm.
A client who had a right hemisphere stroke.
The Correct Answer is B
Choice A rationale:
A client who had blood drawn from the right antecubital area 1 hour ago does not require blood pressure measurement from the left arm. Blood drawing from one arm does not affect the accuracy of blood pressure measurement in the opposite arm.
Choice B rationale:
A client who has a right peripherally inserted central catheter (PICC) line should have blood pressure measured from the opposite arm to avoid disrupting the PICC line.
Choice C rationale:
A client who had dialysis and is using an arteriovenous shunt in the left lower forearm should have blood pressure measured from the opposite arm. Using the arm with an arteriovenous shunt for blood pressure measurement can lead to inaccurate readings and potentially damage the shunt, disrupting the client's dialysis treatment.
Choice D rationale:
A client who had a right hemisphere stroke does not necessarily require blood pressure measurement from the left arm. Stroke location does not impact the choice of the arm for blood pressure measurement; other factors, such as vascular access devices or medical procedures, are more relevant in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A client who has cellulitis and is receiving oral antibiotics every 8 hr has a mild to moderate infection that can be managed at home with proper wound care and medication adherence. The client does not require hospitalization unless there are signs of systemic infection or complications.
B. A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex has a high risk of aspiration and airway obstruction due to impaired swallowing function. The client requires close monitoring and intervention until the gag reflex returns, which can take several hours or longer depending on the type and amount of anesthesia used.
C. A mother and their newborn 12 hr postdelivery have not completed the minimum recommended stay of 24 to 48 hours for uncomplicated vaginal deliveries or 72 to 96 hours for cesarean deliveries, according to the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The mother and their newborn require assessment, education, support, and follow-up care to ensure their health and well-being.
D. A client who has lower extremity weakness and is newly admitted for observation has an undiagnosed condition that could indicate a serious neurological or vascular problem, such as stroke, spinal cord injury, or peripheral artery disease. The client requires diagnostic testing, evaluation, treatment, and rehabilitation to prevent further deterioration or complications.
Correct Answer is ["A","B"]
Explanation
- A: Correct. Broccoli is a vegetable that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.
- B: Correct. Yogurt is a dairy product that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.
- C: Incorrect. Pepperoni pizza contains pepperoni, cheese, and tomato sauce, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.
- D: Cream cheese is a dairy product that contains little or no tyramine and is therefore, safe in a client taking phenelzine.
- E: Incorrect. Bologna sandwich contains bologna, bread, and mayonnaise, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.
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