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?

Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed.

Advise the UAP to document the last blood pressure obtained on the client's graphic sheet.

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.

Answer and Explanation

The Correct Answer is C

A. Demonstrating how to palpate the popliteal pulse is not a suitable alternative for measuring blood pressure when the client cannot be measured in the arms or legs. Palpating peripheral pulses does not provide accurate blood pressure measurements.

B. Advising the UAP to document the last blood pressure obtained is insufficient because it does not address the need for current blood pressure monitoring. Documentation of past
measurements does not provide real-time information about the client's hemodynamic status.

C. Estimating the blood pressure by assessing the pulse volume of the client's radial pulses is a reasonable alternative when traditional blood pressure measurement sites are inaccessible. Although not as accurate as traditional methods, assessing the strength of peripheral pulses can provide valuable information about perfusion and blood pressure status.

D. Documenting why the blood pressure cannot be accurately measured is important for record- keeping but does not address the need for ongoing blood pressure monitoring or provide an alternative method for assessment.

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Correct Answer is D

Explanation

A. Removing dentures or other oral appliances is not directly related to managing obstructive sleep apnea. While it may be necessary for certain procedures or assessments, it does not address the client's OSA during narcotic administration.

B. Elevating the head of the bed to a 45-degree angle is a standard practice to prevent aspiration during narcotic administration, but it does not specifically address the client's obstructive sleep apnea.

C. Lifting and locking the side rails in place is important for client safety but does not directly address the client's obstructive sleep apnea.

D. Applying the client's positive airway pressure (PAP) device is crucial for managing obstructive sleep apnea, especially when administering a narcotic analgesic, which can further depress respiratory function. The PAP device helps maintain airway patency and prevent apneic episodes, reducing the risk of respiratory complications in clients with OSA.

A. Verify the prothrombin time (PT). B. Administer prescribed sedative. C. Select a monitor lead with a tall R wave. D. Activate the synchronization mode.

Correct Answer is D

Explanation

A. Verify the prothrombin time (PT).
While it is important to verify coagulation status in patients with atrial fibrillation to ensure they are not at high risk for bleeding, this is not the most critical step immediately prior to
cardioversion. The PT is more relevant if anticoagulation therapy is being managed.

B. Administer prescribed sedative.
Administering a sedative is important for patient comfort during the procedure, but it is not the most critical step that directly affects the success and safety of the cardioversion itself.

C. Select a monitor lead with a tall R wave.
Selecting a monitor lead with a tall R wave helps in accurately synchronizing the cardioversion shock with the R wave, but this is secondary to activating the synchronization mode which is critical to avoid delivering a shock during the vulnerable period of the cardiac cycle.

D. Activate the synchronization mode.
This is the correct answer. The most important action before deploying the current for cardioversion is to ensure the defibrillator is in synchronization mode. Synchronization ensures that the electrical shock is delivered at the correct time during the cardiac cycle, specifically on the R wave of the QRS complex, to avoid inducing ventricular fibrillation. This is crucial for
patient safety.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer a narcotic analgesic to a client with a fractured femur who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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