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

- A. Incorrect. Evaluating dietary intake requires nursing judgment and knowledge of nutrition and eating disorders. This task should not be delegated to an AP.

- B. Incorrect. Measuring vital signs of a postoperative client requires nursing assessment and monitoring for complications. This task should not be delegated to an AP.

- C. Correct. Arranging the lunch tray for a client who has a hip fracture is a routine task that does not require nursing skills or judgment. This task can be delegated to an AP.

- D. Incorrect. Assessing I&O for a client who is receiving dialysis requires nursing knowledge of fluid and electrolyte balance and renal function. This task should not be delegated to an AP.

A. Keep the client's television on with the volume low B. Insert an indwelling urinary catheter to minimize interaction with the client C. Consult the provider regarding administering a mild sedative on a schedule D. Move the client to a room near the nurses' station

Correct Answer is D

Explanation

Move the client to a room near the nurses' station.

A. Keep the client's television on with the volume low: This is incorrect because it does not address the client's safety or agitation. The television might also be a source of confusion or stimulation for the client.
B. Insert an indwelling urinary catheter to minimize interaction with the client: This is incorrect because it is an invasive and unnecessary procedure that increases the risk of infection and trauma. It also violates the client's dignity and autonomy.
C. Consult the provider regarding administering a mild sedative on a schedule: This is incorrect because it is not the first action to take. The nurse should first assess the client's condition and identify possible causes of disorientation and combativeness, such as pain, infection, medication side effects, or delirium. Sedatives should be used as a last resort and only with informed consent.
D. Move the client to a room near the nurses' station: This is correct because it allows for close observation and supervision of the client, which can prevent injury and promote safety. It also facilitates frequent interaction and reassurance from the staff, which can reduce anxiety and agitation.

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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?