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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["1.5"]

Explanation

- Determine the total milligrams needed: The prescription is for 600 mg.

- Identify the concentration of the medication available: The vial is labeled as 400 mg/mL.

- Calculate the volume required to provide the prescribed dose: Divide the total milligrams needed by the concentration.

- Perform the calculation: 600/400= 1.5

Answer = 1.5 ml

A. Clean the site using sterile gauze and sterile water. B. Place client in a private room. C. Avoid hand sanitizer after the procedure. D. Place the soiled dressing in a red biohazard bag. E. Use sterile gloves to remove

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Clean the site using sterile gauze and sterile water.
- Indicated: The turban dressing should be changed using sterile techniques to prevent infection and ensure proper wound care.
Place client in a private room.
- Not Indicated: The client is already on contact precautions for MRSA, so the private room is a general requirement and not a specific intervention for the dressing change.
Avoid hand sanitizer after the procedure.
- Not Indicated: Hand sanitizer is typically used before and after procedures. For MRSA contact precautions, hand hygiene is critical, and proper hand washing or using hand sanitizer is recommended after the procedure.
Place the soiled dressing in a red biohazard bag.
- Indicated: The soiled dressing is considered contaminated and should be disposed of in a red biohazard bag to prevent the spread of infection.
Use sterile gloves to remove the old dressing.
- Indicated: Sterile gloves are required for removing and replacing the dressing to maintain a sterile field and prevent infection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["1.5"]

Explanation

Exhibits The practical nurse (PN) is preparing to change the turban dressing. For each intervention, click to indicate whether it is indicated or not indicated for the dressing change. Each row must have one

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

In implementing the plan of care, which data should the practical nurse (PN) obtain first for a client with a sleep pattern disturbance?

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Exhibits The client likely has dropdown related to dropdown

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