The nurse applies a blood pressure cuff around a client's left thigh. To measure the client's blood pressure, where should the diaphragm of the stethoscope be placed? (Mark the location on one of the images.)
The Correct Answer is "{\"xRanges\":[24.75253686935637,42.04549690532573],\"yRanges\":[62.826215561361366,80.16865945855535]}"
To measure blood pressure from the left thigh, the diaphragm of the stethoscope should be placed over the popliteal artery, which is located behind the knee. This placement allows you to auscultate the Korotkoff sounds accurately when measuring thigh blood pressure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A.Monitoring an intravenous infusion rate involves the assessment of fluid delivery and the mechanical function of medical equipment. This task requires specialized knowledge of pharmacology and potential complications like infiltration or circulatory overload, which are outside the UAP's training. Only a licensed nurse can legally monitor and validate the accuracy of an IV pump schedule. Delegating this to unlicensed staff poses a significant risk for medication errors and fluid imbalances.
B. Titrate oxygen to the prescribed parameters: Adjusting oxygen requires clinical judgment and assessment of respiratory status, including oxygen saturation and signs of hypoxia. This is a nursing responsibility and cannot be delegated to a UAP.
C. Insert a urinary catheter for an uncomplicated client: Catheter insertion is a sterile procedure that requires nursing knowledge and skill. Delegation to a UAP is not permitted due to the risk of infection and need for proper technique.
D. Procuring blood or platelet products from the blood bank is a standard administrative task that falls within the UAP scope of practice. This activity does not require clinical judgment, nursing assessment, or the performance of a sterile procedure. The nurse remains responsible for the final verification of the blood product at the bedside, but the physical transport is a safe delegation. It allows the nurse to remain on the unit for higher-priority clinical duties.
Correct Answer is A
Explanation
A. Palpate the client's suprapubic area for distention: Palpating for bladder distention helps determine if urinary retention is present, which is common in older men with possible benign prostatic hyperplasia (BPH). Assessing retention is a priority because unresolved urinary obstruction can lead to hydronephrosis or kidney damage.
B. Instruct in effective techniques to cleanse the glans penis: Proper hygiene is important for preventing infection, especially in uncircumcised males, but it does not address the client’s primary problem of urinary retention and obstructive symptoms.
C. Obtain a urine specimen for culture and sensitivity: While urinary tract infections can occur in clients with urinary retention, the presenting symptoms here are more indicative of obstruction due to prostate enlargement. A culture may be ordered later, but not the first step.
D. Advise the client to maintain a voiding diary for one week: A voiding diary provides helpful long-term information about urinary patterns, but it does not address the acute issue of a bladder that may be distended and retaining urine.
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