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. Administering acetaminophen can help reduce fever and discomfort but does not directly address the respiratory distress indicated by tachypnea and stridor.
B. Monitoring the child's oxygen saturation level via pulse oximeter is essential to assess the severity of the respiratory distress. It provides critical information on the child's oxygenation status and helps guide further interventions.
C. Encouraging the child to drink adequate amounts of cool, clear liquids is beneficial for hydration but does not directly address the acute respiratory symptoms of irritability, tachypnea, and stridor.
D. Instructing the mother to play with the child for stimulation and distraction may help alleviate irritability but does not address the underlying respiratory distress, which requires immediate attention.

A. Document suspected abuse using the physical findings as supporting evidence. B. Establish trust with the client to ensure basic needs and open communications are met. C. Medicate the client as prescribed to ensure adequate rest and interventional therapies. D. Contact social services to investigate the personnel at the skilled care facility.

Correct Answer is B

Explanation

A. While documentation is essential, establishing a trusting relationship with the client is a more immediate priority to address their basic needs and gather information.
B. Establishing trust with the client is crucial to ensure their basic needs are met and to create an environment where the client feels safe to communicate openly. This foundational step is necessary before other interventions can be effectively implemented.
C. Medicating the client as prescribed is important for their overall care but does not address the immediate need to build trust and assess their situation comprehensively.
D. Contacting social services is a necessary step if abuse is suspected, but it should follow the initial assessment and establishment of trust with the client to gather accurate information.

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Naxlex Comprehensive Predictor Exams

In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

A client who is experiencing paralysis of the left arm curses at the practical nurse (PN) and throws a hairbrush against the wall using the right arm. How should the PN respond?

An older adult client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The practical nurse (PN) notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the PN to implement?

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

The spouse of a hospitalized client asks the practical nurse (PN) for acetaminophen for a tension headache. Which action should the PN take?

The practical nurse (PN) is assisting a client to the bathroom after a right cataract extraction. The client has an eye shield over the right eye. How should the PN assist the client during ambulation?

A client with a malabsorption syndrome has a low serum calcium level. The practical nurse should monitor the client for which problem?

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. Which question is most important for the practical nurse (PN) to include in the assessment of this client?