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.
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Related Questions
Correct Answer is B
Explanation
To find the rate of the pump in ml/hour, you need to first convert the client’s weight from pounds to kilograms. You can do this by dividing the weight by 2.2046 or multiplying it by 0.454.
For example:
297 lbs / 2.2046 = 134.72 kg or 297 lbs x 0.454 = 134.72 kg
Then, you need to multiply the client’s weight in kilograms by the ordered dose in units/kg/hour to get the total units per hour.
For example:
134.72 kg x 12 units/kg/hour = 1616.64 units/hour
Next, you need to set up a proportion to find the rate of the pump in ml/hour using the supplied medication concentration.
For example:
25,000 units / 500 ml = 1616.64 units / X ml Cross-multiply and solve for X:
25,000 x X = 808320 X = 808320 / 25000 X = 32.33 ml/hour
Finally, you need to round your answer to the nearest tenth of a ml/hour as per the medication administration guidelines.
For example:
32.33 ml/hour ≈ 32.3 ml/hour
Therefore, the rate of the pump is 32.3 ml/hour.
Choice A is wrong because it uses a different conversion factor for pounds to kilograms (1 lb = 0.5 kg) which is not accurate.
Choice C is wrong because it uses a different ordered dose (10 units/kg/hour) which is not what the provider has written.
Choice D is wrong because it uses a different supplied medication concentration (20,000 units in 500 ml) which is not what is available.
Correct Answer is ["A","B","C","D"]
Explanation
The correct answers are Choices A, B, C, and D.Choice A rationale:Inspection of lips and mucous membranes is a vital assessment technique for hydration status. Dryness or cracking of the lips and mucous membranes can indicate dehydration, as these areas are often affected by fluid loss. Observing these features helps healthcare providers assess the client's hydration level effectively.Choice B rationale:Pinching the skin on the back of the hand tests skin turgor, which is a reliable indicator of hydration status. If the skin does not return to its normal position quickly after being pinched, it suggests decreased skin elasticity due to dehydration. This method provides a quick visual and tactile assessment of fluid levels in the body.Choice C rationale:Measuring pulse and blood pressure is essential in evaluating hydration status. Changes in blood pressure (especially orthostatic hypotension) and pulse rate can indicate fluid volume changes in the body. An increased heart rate may suggest dehydration, while low blood pressure can indicate significant fluid loss.Choice D rationale:Obtaining the client's daily weight is a crucial method for monitoring hydration status. Weight fluctuations can provide insight into fluid retention or loss over time. A sudden decrease in weight may indicate dehydration, while an increase could suggest fluid overload or retention issues.Choice E rationale:Palpating scalp and hair distribution is not a common or effective method for assessing hydration status. While scalp condition may reflect overall health, it does not provide direct information about hydration levels compared to other methods listed.
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