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 ["A","B","D"]
Explanation
A. Oxygen Concentration of the Ambient Air
The oxygen concentration of the ambient air affects how much oxygen the child could have been exposed to once retrieved from the pool. If the child was submerged in water, the ability to access oxygen from the environment was compromised, which contributes to the level of hypoxemia experienced. Ambient air oxygen concentration is a crucial factor in determining how long it might take for hypoxemia to develop or improve after submersion.
B. Temperature of Water
The temperature of the water affects the child’s physiology during submersion. Cold water can lead to a more rapid decrease in core body temperature and can influence the child’s respiratory and cardiovascular responses, potentially affecting the degree of hypoxemia.
C. The Weight of the Child
The weight of the child does not significantly impact the level of hypoxemia experienced during submersion. While it might influence the child’s ability to stay afloat or the rescue process, it does not directly affect hypoxemia levels.
D. The Amount of Time the Child Was Submerged
The duration of submersion is a critical factor in determining the level of hypoxemia. Longer submersion times result in more significant oxygen deprivation and a greater degree of hypoxemia, which can impact the severity of respiratory and cardiac complications.
E. Whether or Not Anyone Witnessed the Fall into the Pool
While witnessing the fall might be relevant for understanding the context of the incident, it does not directly affect the level of hypoxemia experienced during the submersion. The key factors are related to the conditions and duration of the submersion itself
Correct Answer is A
Explanation
A. Acknowledging the client's anger and offering to listen validates their feelings and provides an opportunity for the client to express their emotions. This approach can help de-escalate the situation and address the underlying frustrations related to their condition.
B. Playing soft music might be soothing but does not directly address the client's expressed anger or the immediate situation. It is not as effective as acknowledging and listening to the client's concerns.
C. Initiating deep breathing exercises might be helpful but is less effective than directly acknowledging the client's anger and providing a space for them to talk about their feelings.
D. Offering to return later may avoid the immediate conflict but does not address the client’s current emotional state or provide support. It is better to engage with the client in the moment to manage their anger and offer support.
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