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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administering cholera vaccines can help prevent further cases but is not the immediate priority for those already infected.
B. Administering prophylactic antibiotics is important but not the highest priority compared to addressing the acute symptoms of cholera.
C. Isolating all infectious diarrhea victims helps prevent the spread of infection but does not address the immediate life-threatening dehydration and electrolyte imbalance.
D. Providing fluid and electrolyte replacement is the highest priority as cholera causes severe dehydration and electrolyte imbalance, which can be fatal if not treated promptly. Immediate rehydration is crucial to save lives.
Correct Answer is B
Explanation
A. Acquiring coping skills is important, but the immediate focus for discharge planning is on practical goals related to managing daily activities and maintaining independence rather than on long-term psychological coping.
B. Conserve energy is the most important goal for a client with rheumatoid arthritis preparing for discharge. Managing energy effectively helps clients cope with fatigue and pain, which are common challenges in daily life with rheumatoid arthritis.
C. Adapting self-care skills is also important but is a broader goal that includes conserving energy as a component. Effective energy management is a key aspect of self-care for clients with rheumatoid arthritis.
D. Improving body image is a valid goal but is not the most urgent concern for discharge planning. The primary focus should be on practical aspects of managing rheumatoid arthritis in daily life.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.