The practical nurse (PN) enters the room of a client who underwent a mastectomy eight hours ago. The PN observes the unlicensed assistive personnel (UAP) preparing to measure the client's blood pressure using an automated blood pressure device on the client's operative side. Which action should the PN implement?

Review the client's blood pressure as soon as the UAP records the measurement.

Instruct the UAP to measure the client's blood pressure on the non-operative side.

Ensure that the client's arm remains elevated after the blood pressure is recorded.

Advise the UAP to use a manual blood pressure cuff for a more accurate reading.

Answer and Explanation

The Correct Answer is B

A. Reviewing the blood pressure measurement is not the primary concern here; the issue is that the UAP is using the incorrect arm for the measurement.
B. The blood pressure should be measured on the non-operative side. Measuring on the operative side can cause discomfort, potential injury, or interfere with the healing process.
C. Elevating the arm after recording the blood pressure is not a standard requirement post-mastectomy. The immediate concern is the proper measurement site for the blood pressure.
D. A manual blood pressure cuff is not required for accuracy in this situation; the key issue is to use the non-operative arm for measurement.

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Correct Answer is B

Explanation

A. Protecting the client's left side during transfers is not directly related to addressing neglect syndrome. Clients with right hemisphere strokes may neglect the left side, but the UAP should be guided to approach from the left to help manage the neglect.
B. Demonstrating to the UAP how to approach the client from the left side helps manage the effects of neglect syndrome. Clients with right hemisphere strokes may not be aware of or may ignore the left side, so approaching from this side can improve the client’s awareness and safety.
C. Observing interactions between the client and family members might provide insights into the client’s condition but is not a direct intervention for managing neglect syndrome. The focus should be on practical strategies to help the client with neglect.
D. Asking the UAP to leave the room and assessing the client for bruising does not address the immediate needs of managing neglect syndrome. The priority is to ensure the client is safely engaged and managed, rather than performing a solitary assessment.

A. Measure urinary output. B. Auscultate all lung fields. C. Check mental acuity. D. Inspect for sacral edema.

Correct Answer is B

Explanation

A. Measure urinary output.
Measuring urinary output is important for monitoring fluid balance but is not the most critical intervention for assessing left-sided heart failure specifically.
B. Auscultate all lung fields.
Auscultating lung fields is crucial for assessing signs of pulmonary edema, a key symptom of left-sided heart failure. It provides direct information about the severity of the condition and guides further management.
C. Check mental acuity.
Checking mental acuity can be useful but is not the most critical intervention for managing left-sided heart failure. It is less directly related to evaluating the severity of heart failure compared to lung auscultation.
D. Inspect for sacral edema.
Inspecting for sacral edema is more relevant for right-sided heart failure. For left-sided heart failure, the priority is evaluating pulmonary symptoms, not peripheral edema.

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Naxlex Comprehensive Predictor Exams

The practical nurse (PN) and unlicensed assistive personnel (UAP) are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. Which action should the PN implement?

Correct Answer is B

Explanation

The practical nurse (PN) is assessing an older adult client with left-sided heart failure (HF). Which intervention is most important for the PN to implement?

Correct Answer is B

Explanation

Which client information is most important for the practical nurse (PN) to consider when providing instructions to the unlicensed assistive personnel (UAP) about providing morning care to a postoperative client?

Before administering zolpidem at bedtime, which client assessment should the practical nurse (PN) complete?

At 1200, the practical nurse (PN) learns that a client's 0900 dose of an anticonvulsant was not given. The next scheduled dose is at 2100. Which action should the PN take?

The unlicensed assistive personnel (UAP) reports to the practical nurse (PN) that an older adult client has a radial pulse of 55 beats/minute. Which intervention should the PN implement first?

The practical nurse (PN) administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory values should the PN monitor? Select all that apply.

An unlicensed assistive personnel (UAP) is assisting with the care of a client with a peripherally inserted central venous catheter (PICC). Which guidance should the practical nurse (PN) provide to the UAP?

The practical nurse (PN) is assigning tasks to an unlicensed assistive personnel (UAP) who is giving basic care to a group of residents in a long-term care facility. Which client's task should be completed by a PN, rather than the UAP?