The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?
Estimate the blood pressure by assessing the pulse volume of the client's radial pulses.
Document why the blood pressure cannot be accurately measured at the present time.
Advise the UAP to document the last blood pressure obtained on the client's graphic sheet.
Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed.
The Correct Answer is D
A. Estimating blood pressure based on the strength or quality of the radial pulse is not a reliable method. Pulse volume can provide only a very rough sense of perfusion but does not give a numeric measurement of systolic or diastolic pressure. Relying on this method could lead to inaccurate assessment, delayed recognition of hypotension or hypertension, and inappropriate clinical interventions, putting the client at risk.
B. While it is essential to document the limitations in obtaining vital signs, documentation alone does not resolve the issue. The client still needs accurate and timely blood pressure measurements for safe monitoring and care, especially if they have a condition that could compromise hemodynamic stability. Simply recording that measurement is not possible fails to meet the standard of care.
C. Using a previous blood pressure reading is unsafe because it does not reflect the client’s current condition. Vital signs can change rapidly due to fluid shifts, pain, medications, or other medical issues. Documenting an old reading can mislead the care team and result in inappropriate interventions or delayed response to changes in the client’s status.
D. This is the most appropriate and safe action. When the upper extremities are unavailable due to casts or injury, alternative validated sites, such as the popliteal artery, should be used. The nurse can teach the UAP how to position the client correctly, flexing the knee while supine, to allow proper cuff placement and accurate measurement. This ensures the client receives safe and reliable monitoring, and the staff is competent in using alternative techniques when standard sites are inaccessible.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Lymphangitis is characterized by inflammation of the lymphatic vessels and is often associated with red streaks and tenderness. The absence of inflammation and tenderness suggests a different etiology.
B. Malignancy is suggested by the presence of a large, nontender, hardened lymph node. These characteristics are commonly associated with metastatic spread of cancer to the lymph nodes. Further diagnostic testing, such as biopsy, would be warranted to confirm malignancy.
C. Viral infection may cause lymphadenopathy, but typically, the lymph nodes are tender and may be enlarged but not necessarily hardened. The absence of tenderness and the hardened consistency of the lymph node suggest a different etiology.
D. Bacterial infection can cause lymphadenopathy, which may be tender and enlarged, but the nontender, hardened nature of the lymph node in this case is more indicative of malignancy
rather than a bacterial infection.
Correct Answer is ["A","C","F","G"]
Explanation
A. Humidifier bottle
Rationale: A humidifier bottle is often used with oxygen therapy to add moisture to the oxygen, preventing dryness of the nasal passages and throat. It is important for patient comfort, especially when oxygen is administered at higher flow rates for prolonged periods.
B. Lamb's wool
Rationale: Lamb's wool is not needed for starting oxygen therapy. It is typically used to provide padding and comfort in other situations, such as preventing pressure sores, but it has no role in the administration of oxygen.
C. Flowmeter
Rationale: A flowmeter is necessary to regulate the flow rate of oxygen. It ensures that the client receives the prescribed amount of oxygen (3 L/minute in this case), making it an essential component for administering oxygen therapy.
D. Tape
Rationale: Tape is not required for administering oxygen via a nasal cannula. It might be used to secure tubing in other contexts, but it is not specifically needed for starting oxygen therapy. The nasal cannula usually stays in place without the need for tape.
E. Suction cannister
Rationale: A suction canister is used in suctioning procedures to collect secretions and is not needed for starting oxygen therapy. It is relevant for managing airway secretions but unrelated to the administration of oxygen.
F. Nasal cannula
Rationale: A nasal cannula is the device through which oxygen is delivered to the client. It is specifically mentioned in the order and is essential for administering the oxygen.
G. Sterile water
Rationale: Sterile water is used to fill the humidifier bottle to provide humidified oxygen. This helps to prevent the drying effects of oxygen therapy on the mucous membranes, enhancing patient comfort.
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