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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. The date of previous diagnostic tests may be important, but it is secondary to immediate safety concerns like allergies.
B. Information about the patient's living situation can be useful for discharge planning but is not the most urgent piece of information.
C. Previous treatment for illnesses is important but does not supersede immediate health threats like allergies.
D. Knowing any allergies to medications is critical to avoid potentially harmful reactions. This is a priority when beginning care, as it informs medication administration and treatment options.

A. 62 beats/min. B. 59 beats/min. C. 64 beats/min. D. 60 beats/min.

Correct Answer is B

Explanation

A. Bradycardia is defined as a heart rate lower than 60 beats per minute. Therefore, 62 beats per minute is not bradycardic.
B. 59 beats per minute would be considered bradycardic, as it is below 60.
C. 64 beats per minute is within normal limits.
D. 60 beats per minute is on the threshold of bradycardia but typically is still within normal limits for some individuals.

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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)

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