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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Serum potassium. Insulin therapy causes potassium to move into cells, which can lead to hypokalemia. Monitoring serum potassium is critical because significant drops can lead to cardiac arrhythmias and other complications.
B. Urine ketones. While monitoring ketones is important for assessing the resolution of DKA, it is not as immediately critical as monitoring potassium levels.
C. Serum sodium. Sodium levels are important but typically do not change as rapidly as potassium levels during DKA treatment.
D. Blood urea nitrogen (BUN). BUN levels provide information about kidney function and hydration status but are less immediately critical than potassium levels in the context of insulin therapy for DKA.
Correct Answer is C
Explanation
A. Offer the client oral fluids. Offering fluids is important but is not directly related to turning the client or managing the urinary catheter.
B. Assess the breath sounds. Assessing breath sounds is beyond the scope of practice for a UAP.
C. Empty the urinary drainage bag. This action helps maintain catheter function and reduces the risk of infection by preventing urine from backing up in the bladder.
D. Feed the client a snack. Feeding the client is important but is not related to turning the client or managing the urinary catheter.
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