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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","D","E"]

Explanation

A. Subdural hemorrhage
The head CT was negative for bleeding or edema, making a subdural hemorrhage unlikely.
B. Respiratory distress
Given the history of drowning and the current signs of respiratory acidosis (pH 7.31, PaCO2 51), the child is at high risk for respiratory complications, including distress.
C. Hyperthermia
Hyperthermia is not a typical immediate complication following drowning in cool water, and the current body temperature of the child is within the normal range.
D. Cerebral edema
Although the initial CT scan is negative for edema, secondary cerebral edema can develop hours after the incident, especially in cases of significant hypoxemia.
E. Acute asphyxia
The initial incident of drowning and the resultant hypoxemia (as indicated by abnormal blood gases) place the child at risk for complications related to acute asphyxia.
F. Hypertension
The child's blood pressure is currently within normal limits, and hypertension is not a common immediate complication following drowning.

A. Moisture. B. Elasticity. C. Color. D. Temperature.

Correct Answer is C

Explanation

A. Moisture is important for skin assessments but does not directly affect the accuracy of a temporal artery temperature measurement.
B. Elasticity is part of skin turgor assessments and does not impact the accuracy of the temperature reading from a temporal artery scanner.
C. Assessing skin color is crucial because variations in skin color can affect the accuracy of the temporal artery temperature measurement. For accurate results, the skin should be clean and free of color alterations.
D. Checking the temperature of the skin is the outcome of the measurement process rather than a preliminary assessment for a temporal artery scanner.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Review H and P, nurse's note, laboratory results, prescriptions, and imaging studies. What complications should the practical nurse (PN) monitor for in the next 6 to 8 hours? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

The practical nurse (PN) positions a temporal artery scanner as seen in the picture. Before obtaining a temperature measurement, which assessment of the skin should the PN complete?

Correct Answer is C

Explanation

In administering nystatin suspension to the gums of an infant with a candida infection, which approach should the practical nurse (PN) use?

In which client situation should the practical nurse assess for the presence of Cheyne-Stokes respirations?

The practical nurse (PN) is assisting with the plan of care for a client who is receiving the nonsteroidal anti-inflammatory drug ketorolac for painful muscle spasms of the back. Which intervention should the PN include in the client's plan of care?

Exhibits Based on the current focused assessment, what prescriptions should the practical nurse (PN) ask the health care provider to add? Select all that apply.

According to the Centers for Disease Control (CDC) and Prevention, what disease(s) are reportable infectious diseases? Select all that apply.

When the practical nurse (PN) attempts to assist an 18-year-old client with a mild mental disability to ambulate on the first postoperative day after an appendectomy, she becomes angry and yells at the PN, "Get out of here! I'll get up when I'm ready!" Which response is best for the PN to make?

A client with acute kidney injury (AKI) is admitted with an elevated heart rate and an elevated blood pressure. Which intervention should the practical nurse (PN) implement?