A client with a history of a right radical mastectomy arrives on the postoperative unit following surgical repair of a fractured left radius and application of a short arm cast. Which action should the practical nurse implement while obtaining the client's blood pressure (BP)?
Use a large cuff to obtain BP readings on either thigh.
Measure all vital signs every 2 hours except the BP.
Obtain manual BP readings with a cuff on the left arm.
Quickly release air from BP cuff on the right arm.
The Correct Answer is A
Choice A reason: Using a large cuff to obtain BP readings on either thigh is the appropriate action. With a history of a right radical mastectomy, blood pressure should not be taken on the right arm due to the risk of lymphedema. The left arm is also not suitable due to the recent surgery and cast. Therefore, the thigh is the best alternative site for accurate BP measurement.
Choice B reason: Measuring all vital signs every 2 hours except the BP is not appropriate because BP is a critical vital sign that needs to be monitored regularly, especially in postoperative clients. Omitting BP measurements could miss important changes in the client's condition.
Choice C reason: Obtaining manual BP readings with a cuff on the left arm is not recommended as the client has a recent surgical repair and cast on the left arm. This can cause discomfort and may not provide accurate readings.
Choice D reason: Quickly releasing air from the BP cuff on the right arm is not suitable due to the client's history of right radical mastectomy. This practice could exacerbate the risk of developing lymphedema in the affected arm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Initiating contact isolation precautions is not necessary for psoriasis. Psoriasis is not an infectious or contagious condition, so isolation is not required. The focus should be on managing symptoms and providing appropriate care to alleviate the client's discomfort.
Choice B reason: Explaining the need to keep the affected areas dry is not an appropriate action for psoriasis management. Psoriasis is characterized by dry, scaly patches of skin, and keeping the areas dry may worsen the condition. It is important to keep the skin moisturized and hydrated to reduce flaking and discomfort.
Choice C reason: Preparing the client for allergen testing is not relevant in this context. Psoriasis is an autoimmune condition, not an allergic reaction. Allergen testing is not typically used in the diagnosis or management of psoriasis. The focus should be on addressing factors that can exacerbate symptoms, such as stress, infections, and certain medications.
Choice D reason: Reviewing stress reduction strategies with the client is the most appropriate action. Stress is known to be a significant trigger for psoriasis flare-ups. By helping the client identify and implement stress reduction techniques, the PN can assist in managing the client's symptoms and improving their overall well-being. Techniques such as mindfulness, relaxation exercises, and counseling can be beneficial in reducing stress and minimizing psoriasis symptoms.
Correct Answer is C
Explanation
Choice A reason: Evaluating the return of the gag reflex is important for assessing a client's ability to protect their airway and for readiness to eat or drink after surgery. However, it is not the immediate priority when a client is repeatedly swallowing, which can indicate bleeding.
Choice B reason: Demonstrating relaxation techniques can be beneficial for managing pain and anxiety, but it does not address the immediate concern of potential postoperative bleeding in a client who is repeatedly swallowing.
Choice C reason: Using a penlight to assess the pharynx for bleeding is the priority action. Repeated swallowing after rhinoplasty can indicate bleeding, and assessing the pharynx allows the nurse to identify and address any postoperative hemorrhage promptly.
Choice D reason: Administering an intravenous analgesic per PRN protocol may help manage pain, but it is not the priority action. The primary concern is to check for potential bleeding, which is indicated by the repeated swallowing.
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