The nurse observes the unlicensed assistive personnel (UAP) obtain vital signs on four adult clients.
For which client should the nurse intervene to redirect to use of proper method?
Using automatic BP cuff with shivering client with history of an irregular heart rate.
Pulling the client’s ear pinna backward, up and out to obtain a tympanic membrane temperature.
Counting the client’s radial pulse who is supine with the forearm straight alongside the body.
Counting the respirations for one full minute for a client with tachypnea.
The Correct Answer is A
Using an automatic BP cuff with a shivering client with a history of an irregular heart rate can result in inaccurate and low readings.
This is because shivering can interfere with the cuff inflation and deflation, and an irregular heart rate can affect the accuracy of the device.
The nurse should intervene and use a manual BP cuff with a stethoscope instead.
Choice B is wrong because pulling the client’s ear pinna backward, up and out to obtain a tympanic membrane temperature is the correct technique for adults and older children. This helps to straighten the ear canal and allow the light to reflect on the tympanic membrane, which shares the same vascular artery as the hypothalamus.
Choice C is wrong because counting the client’s radial pulse who is supine with the forearm straight alongside the body is an appropriate method.
The radial pulse can be easily palpated at the wrist, and the supine position and straight forearm do not affect the pulse rate.
Choice D is wrong because counting the respirations for one full minute for a client with tachypnea is a recommended practice.
Tachypnea means rapid breathing, and counting for one full minute can ensure accuracy and detect any variations in the respiratory pattern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This meal selection best demonstrates a client with osteoporosis understands dietary recommendations because it provides adequate amounts of calcium, vitamin D, and protein, which are essential nutrients for bone health.
Choice A is wrong because chicken, carrots, and fresh grapefruit salad do not provide enough calcium or vitamin D for a person with osteoporosis.
Calcium is mainly found in dairy products, leafy green vegetables, and fish with bones. Vitamin D is mainly found in fatty fish, egg yolks, and fortified foods.
Choice C is wrong because green salad, ground beef patty, corn, and applesauce do not provide enough calcium or vitamin D for a person with osteoporosis.
Green salad may contain some calcium depending on the type of greens, but it is not a rich source.
Ground beef patty and corn are low in calcium and vitamin
D. Applesauce does not contain any calcium or vitamin
D. Choice D is wrong because plain omelet, bacon, toast with butter, and strawberries do not provide enough calcium or vitamin D for a person with osteoporosis.
Plain omelet and bacon are high in protein but low in calcium and vitamin
Toast with butter may contain some vitamin D if the bread or butter are fortified, but it is not a rich source.
Strawberries do not contain any calcium or vitamin
Correct Answer is A
Explanation
A client who grimaces during a dressing change is showing a nonverbal sign of pain. Grimacing is an expression of facial muscles that indicates discomfort or distress.
The nurse should record this as a symptom of pain and ask the client to rate the pain using a numeric or visual scale.
Choice B is wrong because an elevated heart rate while exercising is not necessarily a symptom of pain. It could be a normal response to increased physical activity or a sign of other conditions such as anxiety, dehydration, or fever.
Choice C is wrong because crying during a procedure is not a reliable indicator of pain. Crying is an emotional response that can be influenced by many factors such as fear, stress, or sadness.
The nurse should not assume that the client is in pain based on crying alone and should ask the client about the reason for crying and the level of pain.
Choice D is wrong because saying “I feel achy all over” is not a specific description of pain.
Aching is a vague term that can refer to different sensations such as soreness, stiffness, or cramping.
The nurse should ask the client to clarify what kind of pain they are feeling, where it is located, how severe it is, and what makes it better or worse.
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