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
Choice A rationale:
The nurse should suggest, "Give your son a little gift from his new sister," as a strategy to help the preschool-age son adjust to having a new sibling. This approach involves a small token or gift given from the newborn to the older sibling. It helps create a positive association and fosters a sense of connection and acceptance between the siblings. The gift symbolizes the new baby's arrival and can help the older child feel special and valued during this transition.
Choice B rationale:
While spending alone time with the new sister is important, the statement, "Give your son plenty of 'alone time' with his sister," does not address the initial meeting concerns. Alone time is relevant once the siblings have established a bond, but the initial introduction requires a more structured approach to ensure a smooth transition.
Choice C rationale:
Planning for the son to meet his sister for the first time at home is not the most suitable strategy. Hospitals provide a controlled environment with healthcare professionals available, ensuring the safety and well-being of both the mother and the newborn. The initial meeting should occur in a setting where medical assistance is readily accessible in case of any unforeseen circumstances.
Choice D rationale:
Holding the daughter when the son first meets her is a common and natural practice but does not actively involve the son in the process. Providing a gift from the baby to the older sibling fosters a sense of participation and inclusion, making the older child feel more involved and excited about the new sibling's arrival.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
