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
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Correct Answer is ["B","C","D"]
Explanation
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Correct Answer is D
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I give the client his medications when the wife is grocery shopping. This statement would require the nurse to re-evaluate and correct the plan of care because home health aides are not allowed to administer medications in most states. Home health aides can only provide medication reminders, help put the medication into the hands of the user, or assist with self-administration of certain forms of medications.
Giving medications to the client without supervision or delegation by a registered nurse or physician is a violation of the scope of practice and could harm the client.
Choice A is wrong because removing throw rugs from the client’s walking path is a safety measure that can prevent falls and injuries for a client with Alzheimer’s disease.
Choice B is wrong because documenting activities with the client before leaving for the day is a professional responsibility that ensures continuity of care and accountability.
Choice C is wrong because contacting the nurse if there are any questions about the plan of care is a sign of good communication and collaboration that can enhance the quality of care for the client.
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