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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Providing postmortem care for a client who has recently died does not require immediate intervention by the charge nurse, as it is a standard nursing responsibility to provide postmortem care with dignity and respect to the deceased client. The AP can proceed with this task independently.

Choice B rationale:

Performing a simple dressing change on a client's foot is within the scope of practice for an assistive personnel (AP) and does not require immediate intervention by the charge nurse, assuming the AP is competent and trained to perform this task.

Choice C rationale:

Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficile is not sufficient. Alcohol is not effective against C. Difficile spores.

Choice D rationale:

Clean gloves are sufficient for this task, as they do provide adequate protection against the transmission of infections.

A. Droplet B. Airborne C. Contact D. Protective environment

Correct Answer is A

Explanation

Droplet.

The rationale for each choice is as follows:

A. Droplet: Correct. Pneumonia is transmitted by respiratory droplets that are generated by coughing, sneezing, or talking. The nurse should wear a surgical mask and eye protection when caring for the client and maintain a distance of at least 3 feet from the client.
B. Airborne: Incorrect. Airborne precautions are used for diseases that are transmitted by small particles that remain suspended in the air for long periods of time, such as tuberculosis, measles, or chickenpox. The nurse should wear a respirator and place the client in a negative-pressure room.
C. Contact: Incorrect. Contact precautions are used for diseases that are transmitted by direct or indirect contact with the client or the client's environment, such as Clostridium difficile, scabies, or MRSA. The nurse should wear gloves and a gown and use dedicated equipment for the client.
D. Protective environment: Incorrect. Protective environment precautions are used for clients who are immunocompromised and at risk of infection from others, such as clients who have had a stem cell transplant or are receiving chemotherapy. The nurse should wear a mask, gloves, and a gown and place the client in a positive-pressure room with HEPA filtration.

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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?

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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?