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 B
Explanation
- A is incorrect because tinnitus, or ringing in the ears, is not an adverse effect of captopril, but rather a symptom of other conditions such as ear infection, noise exposure, or medication toxicity.
- B is correct because cough is a serious adverse effect of captopril, which is an angiotensinconverting enzyme (ACE) inhibitor that can cause angioedema, or swelling of the airways.
- C is incorrect because polyuria, or excessive urination, is not an adverse effect of captopril, but rather a symptom of other conditions such as diabetes mellitus, diabetes insipidus, or diuretic use.
- D is incorrect because blurred vision is not an adverse effect of captopril, but rather a symptom of other conditions such as eye strain, refractive error, or cataract.
Correct Answer is A
Explanation
Choice A rationale:
A blood lead level of 18 mcg/dL in a 9-month-old infant is elevated. The Centers for Disease Control and Prevention (CDC) considers a blood lead level of 5 mcg/dL or higher in children to be concerning. Lead exposure can lead to developmental delays and cognitive impairments. Therefore, this result needs to be reported to the healthcare provider promptly.
Choice B rationale:
Hemoglobin level of 12 g/dL is within the normal range for a 9-month-old infant (11-15 g/dL) There is no need to report this result to the provider.
Choice C rationale:
Iron level of 74 mcg/dL is within the normal range for a 9-month-old infant (50-120 mcg/dL) There is no need to report this result to the provider.
Choice D rationale:
Hematocrit level of 35% is within the normal range for a 9-month-old infant (29-41%) There is no need to report this result to the provider.
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