An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasm when taking the blood pressure using the same arm.
After confirming the presence of the spasms, which action should the nurse take?

Ask the UAP to take the blood pressure in the other arm.

Tell the UAP to use a different sphygmomanometer.

Review the client’s serum calcium level.

Administer a PRN antianxiety medication.

Answer and Explanation

The Correct Answer is C

Choice A rationale
While taking the blood pressure in the other arm might avoid the spasms, it does not address the underlying cause of the spasms. Therefore, this is not the best action for the nurse to take.
Choice B rationale

Using a different sphygmomanometer would not necessarily prevent the spasms from occurring. The spasms are likely not caused by the equipment itself, but rather a physiological issue within the client.
Choice C rationale
The spasms in the client’s hand and fingers could be a sign of hypocalcemia, a condition where there is not enough calcium in the blood. One of the symptoms of hypocalcemia is muscle spasms or tetany. Therefore, reviewing the client’s serum calcium level would be an appropriate action to take.
Choice D rationale
Administering a PRN antianxiety medication would not address the underlying cause of the spasms. While anxiety can cause muscle tension and spasms, there is no indication in the scenario that anxiety is the cause of this client’s symptoms.

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Correct Answer is ["A","B","C","F"]

Explanation

The correct answer is A. Ventilation, B. Neurological status, C. Exposure, F. Circulation.

Choice A: Ventilation Ventilation is a crucial part of the primary survey in trauma assessment. It involves assessing the patient’s respiratory rate and effort, use of accessory muscles, cyanosis, and chest wall movement. The normal respiratory rate for adults is between 12-20 breaths per minute.

Choice B: Neurological status Neurological status is another vital component of the primary survey. It often involves assessing the patient’s level of consciousness, often using tools like the Glasgow Coma Scale (GCS). The GCS score can range from 3 (completely unresponsive) to 15 (responsive).

Choice C: Exposure Exposure involves removing the patient’s clothing to check for any hidden injuries. It’s an essential step in trauma assessment, but there’s no “normal range” for this as it’s a process rather than a measurable variable.

Choice D: Current medications While knowing a patient’s current medications is important in managing their care, it’s not typically part of the primary survey in trauma assessment. This information is usually gathered during the secondary survey.

Choice E: Allergies Like current medications, information about allergies is also crucial in managing patient care, but it’s not part of the primary survey. This information is usually collected during the secondary survey.

Choice F: Circulation Circulation is a critical part of the primary survey. It involves checking the patient’s heart rate, blood pressure, capillary refill time, and looking for any signs of external bleeding. The normal resting heart rate can range between 60-99 beats per minute.

A. Offer the client oral fluids B. Feed the client a snack C. Assess the breath sounds D. Empty the urinary drainage bag

Correct Answer is D

Explanation

Choice A rationale
Offering the client oral fluids is important for hydration, but it is not directly related to the care of an indwelling urinary catheter. The UAP can offer fluids to the client, but this action is not specifically tied to the turning of the client or the care of the urinary catheter.
Choice B rationale
Feeding the client a snack is a task that the UAP may perform, but it is not directly related to the care of an indwelling urinary catheter. The UAP can provide a snack to the client, but this action is not specifically tied to the turning of the client or the care of the urinary catheter.
Choice C rationale
Assessing breath sounds is within the scope of practice for a nurse, not a UAP. While it’s important to monitor a client’s respiratory status, this action is not directly related to the care of an indwelling urinary catheter.
Choice D rationale
Emptying the urinary drainage bag is an appropriate action for the UAP to take each time the client is turned. This action helps to prevent infection, maintain accurate intake and output records, and ensure the comfort and dignity of the client.

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An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse inspects the airway and finds no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.

Correct Answer is ["A","B","C","F"]

Explanation

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. Which additional action should the nurse instruct the UAP to take each time the client is turned?

Correct Answer is D

Explanation

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An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasm when taking the blood pressure using the same arm.
After confirming the presence of the spasms, which action should the nurse take?