A nurse is caring for a group of clients. The nurse should obtain a blood pressure reading using only the left extremity from which of the following clients?

A client who has a peripherally inserted central catheter (PICC) in the left arm

A client who has a right upper extremity arteriovenous fistula

A client who has right-sided weakness due to Parkinson's disease

A client who has left-sided Bell's palsy

Answer and Explanation

The Correct Answer is B

The nurse should obtain a blood pressure reading using only the left extremity from a client who has a right upper extremity arteriovenous fistula. An arteriovenous fistula is a surgical connection between an artery and a vein that is created for hemodialysis access.

Measuring blood pressure on the arm with an arteriovenous fistula can cause damage to the fistula, reduce blood flow, and increase the risk of infection or thrombosis. Therefore, blood pressure should be measured on the opposite arm or on another site such as the leg.

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Correct Answer is B

Explanation

Weight gain 1.1 kg (2.4 lb) in 24 hours indicates fluid retention and possible volume overload, which can worsen kidney function and cause complications such as hypertension, pulmonary edema, and heart failure. The nurse should report this finding to the provider and monitor the client's vital signs, fluid intake and output, and electrolyte levels.

Creatinine 0.8 mL/dL is within the normal range for adults and does not indicate kidney impairment. Peripheral pulses 2+ bilaterally are normal and do not suggest any vascular problems. Urine specific gravity 1.045 is slightly high but not abnormal for a client with acute kidney failure, as it reflects the reduced ability of the kidneys to dilute urine.

A. "Are your immunizations current?" B. Do you have any household pets, such as a cat?" C. "Was anyone in your family recently exposed to a viral disease?" D. "Have you been out of the country in the past 30 days?"

Correct Answer is B

Explanation

Toxoplasmosis is a parasitic infection caused by Toxoplasma gondii, which can be transmitted by contact with cat feces or eating undercooked meat containing cysts. The nurse should ask about the client's exposure to cats or cat litter, as this is a risk factor for acquiring toxoplasmosis, especially in immunocompromised individuals.

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A nurse is caring for a group of clients. The nurse should obtain a blood pressure reading using only the left extremity from which of the following clients?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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