A nurse is caring for a group of clients. From which of the following clients should the nurse obtain a blood pressure reading using only the left extremity?
A client who has a peripherally inserted central catheter (PICC) in the left arm
A client who has left-sided Bell's palsy
A client who has right-sided weakness due to Parkinson's disease
A client who has a right upper extremity arteriovenous fistula
The Correct Answer is D
Choice A reason: While it is generally advised to avoid taking blood pressure readings from an arm with a PICC line to prevent complications, if the right arm cannot be used, as may be the case with the other clients listed, the nurse may have to use the left arm with extreme caution, ensuring not to disrupt the PICC line.
Choice B reason: Bell's palsy affects facial nerves and does not typically impact the measurement of blood pressure. Therefore, there is no contraindication to using the left arm for a blood pressure reading in a client with left-sided Bell's palsy.
Choice C reason: A client with right-sided weakness due to Parkinson's disease can have their blood pressure taken on the left side if the right side is too weak to provide an accurate reading or if using the right side would cause discomfort to the client.
Choice D reason: For a client with a right upper extremity arteriovenous fistula, typically created for dialysis access, blood pressure measurements should not be taken on that arm to avoid damaging the fistula. Therefore, the left arm should be used for blood pressure readings in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Moving the client to a double room may not be effective in preventing wandering and could potentially lead to confusion or agitation if the client is not comfortable with the roommate or the new environment.
Choice B reason: Using a bed alarm is a non-invasive way to alert staff if the client attempts to leave the bed. This can help prevent wandering and ensure the safety of the client without restricting their movement unnecessarily.
Choice C reason: Encouraging participation in activities that provide excessive stimulation is not recommended for clients with dementia, as it can lead to increased confusion, agitation, and potentially exacerbate wandering behaviors.
Choice D reason: The use of chemical restraints, such as sedative medications, should be a last resort and only used when necessary to ensure the safety of the client or others. It is important to use the least restrictive measures first and to always consider the ethical implications of using chemical restraints.
Correct Answer is A
Explanation
Choice A reason: Administering oxygen at 2 L/min is appropriate for clients with emphysema who have hypoxemia. Oxygen therapy should be titrated based on the client's oxygen saturation levels to avoid suppressing the respiratory drive.
Choice B reason: The use of incentive spirometry is beneficial for clients with emphysema as it encourages deep breathing and helps prevent atelectasis. It is an appropriate intervention to include in the plan of care.
Choice C reason: Breathing exercises for clients with emphysema typically focus on prolonging the exhalation phase, not the inhalation phase, to improve airway clearance and reduce the work of breathing.
Choice D reason: Limiting fluid intake is not generally recommended for clients with emphysema unless there are specific contraindications. Adequate hydration can help thin secretions and improve mucus clearance.
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