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?
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.
Estimate the blood pressure by assessing the pulse volume of the client’s radial pulses.
The Correct Answer is A
Choice A rationale
When a client’s blood pressure cannot be measured due to casts on both arms and the client’s position, the most appropriate action for the nurse is to document why the blood pressure cannot be accurately measured at the present time. This is because accurate measurement of blood pressure is crucial for monitoring the client’s health status and making appropriate clinical decisions. If the blood pressure cannot be measured accurately, it is important to document this fact along with the reasons why, so that other healthcare professionals are aware of the situation and can take appropriate action.
Choice B rationale
Advising the UAP to document the last blood pressure obtained on the client’s graphic sheet is not the most appropriate action in this situation. While it might provide some information about the client’s previous blood pressure readings, it does not address the current inability to measure the blood pressure. Furthermore, it could potentially lead to confusion or misinterpretation of the client’s current health status.
Choice C rationale
Demonstrating how to palpate the popliteal pulse with the client supine and the knee flexed is not the most appropriate action in this situation. While palpating the popliteal pulse can provide some information about the client’s circulatory status, it does not provide a measure of blood pressure. Furthermore, this action might not be feasible or appropriate depending on the client’s condition and the presence of casts on both arms.
Choice D rationale
Estimating the blood pressure by assessing the pulse volume of the client’s radial pulses is not the most appropriate action in this situation. While pulse volume can provide some information about the client’s circulatory status, it does not provide a measure of blood pressure. Furthermore, this method of estimating blood pressure is not as accurate or reliable as direct measurement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Mixing the dextrose in a 50 mL piggyback for a total volume of 100 mL is not the best method for administering the medication. This would dilute the dextrose, potentially reducing its effectiveness.
Choice B rationale
Diluting the dextrose in one liter of 0.9% normal saline solution is not the best method for administering the medication. This would significantly dilute the dextrose, potentially reducing its effectiveness.
Choice C rationale
Asking the pharmacist to add the dextrose to a total parenteral nutrition (TPN) solution is not the best method for administering the medication. This would not provide the immediate glucose boost needed to counteract insulin shock.
Choice D rationale
Pushing the undiluted dextrose slowly through the currently infusing IV is the best method for administering the medication. This allows for rapid administration of a concentrated glucose solution, which is necessary to quickly raise blood glucose levels in a patient experiencing insulin shock.
Correct Answer is D
Explanation
Choice A rationale
Offering the client oral fluids is important for hydration, but it is not directly related to the care of an indwelling urinary catheter. The UAP can offer fluids to the client, but this action is not specifically tied to the turning of the client or the care of the urinary catheter.
Choice B rationale
Feeding the client a snack is a task that the UAP may perform, but it is not directly related to the care of an indwelling urinary catheter. The UAP can provide a snack to the client, but this action is not specifically tied to the turning of the client or the care of the urinary catheter.
Choice C rationale
Assessing breath sounds is within the scope of practice for a nurse, not a UAP. While it’s important to monitor a client’s respiratory status, this action is not directly related to the care of an indwelling urinary catheter.
Choice D rationale
Emptying the urinary drainage bag is an appropriate action for the UAP to take each time the client is turned. This action helps to prevent infection, maintain accurate intake and output records, and ensure the comfort and dignity of the client.
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