The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient who has a(n): (Select all that apply)
dialysis shunt.
2-year-old hand amputation.
previous mastectomy.
patent IV line.
Correct Answer : A,C
A. A dialysis shunt requires careful monitoring to avoid damaging the shunt, and blood pressure cuffs should not be applied to the arm with a shunt.
B. A hand amputation does not affect the use of the blood pressure cuff, but care should be taken with the affected area.
C. A previous mastectomy increases the risk of lymphedema, and using a blood pressure cuff on the affected arm could exacerbate this.
D. A patent IV line is not a contraindication for blood pressure measurement, but the nurse should take care not to interfere with the IV.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A blood pressure of 124/84 mm Hg is slightly elevated and falls into the "elevated blood pressure" category.
B. Elevated blood pressure (120-129 systolic and less than 80 diastolic) is considered a risk factor for developing hypertension.
C. Hypertension stage 1 begins at 130/80 mm Hg, not at 124/84 mm Hg.
D. Hypertension stage 2 requires a reading of 140/90 mm Hg or higher.
Correct Answer is A
Explanation
A. Pulse oximetry works by using light absorption to measure the oxygen saturation of hemoglobin in the blood, which typically occurs through the capillary bed in areas like the finger or earlobe.
B. The pulse oximeter does not measure the amount of blood passing through the sensor directly, but rather the oxygen content of the blood.
C. The pulse oximeter does not assess the warmth of the skin as a mechanism for measuring oxygenation.
D. Pulse oximeters measure oxygen saturation levels, not the respiratory rate or blood pressure.
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