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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale
While it’s true that phantom limb pain can be a normal post-surgical sensation, simply reassuring the patient doesn’t address the pain they’re experiencing.
Choice B rationale
Guiding in moving the unaffected limb to override the sensation being experienced is not a recommended intervention for phantom limb pain. Phantom limb pain is a complex phenomenon that is not simply overridden by movement of other body parts.

Choice C rationale
Explaining that the sensations of tingling and pain are not real may invalidate the patient’s experience. Phantom limb pain is a real phenomenon experienced by many amputees. It’s not just a sensation; it’s a type of neuropathic pain that can be severe and debilitating.
Choice D rationale
Affirming that a prosthetic with physical therapy will gradually improve the symptoms is the best non-pharmacological intervention among the choices. Physical therapy, including mirror therapy and other desensitization techniques, can help manage phantom limb pain. The use of a prosthetic can help the patient regain function and mobility, which can also improve their overall well-being and potentially reduce the perception of phantom limb pain.

A. Color, clarity, and odor of urine. B. Patient’s ability to increase fluid intake. C. Patient allergies to antiseptic solutions. D. Previous history of urinary tract infections.

Correct Answer is C

Explanation

Choice A rationale
While the color, clarity, and odor of urine can provide important information about a patient’s overall health and hydration status, it is not the most crucial information to obtain before inserting an indwelling urinary catheter.
Choice B rationale
The patient’s ability to increase fluid intake can be important in managing various health conditions, but it is not the most important information to obtain before this procedure.
Choice C rationale
Knowing if a patient has allergies to antiseptic solutions is crucial before inserting an indwelling urinary catheter. Using an antiseptic solution that a patient is allergic to can lead to serious complications.
Choice D rationale
While a previous history of urinary tract infections can inform the care and management of a patient with an indwelling urinary catheter, it is not the most important information to obtain before the procedure.

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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 providing postoperative care for an adolescent who had a left leg amputation due to osteosarcoma and is experiencing phantom limb pain. What non-pharmacological intervention should the nurse provide?

Correct Answer is D

Explanation

Before inserting an indwelling urinary catheter, which information about the patient is most important for the nurse to obtain?

Correct Answer is C

Explanation

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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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?