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 D

Explanation

Thrombocytopenia is a condition where the blood has a low platelet count, which can impair blood clotting and increase the risk of bleeding. Heparin is an anticoagulant that prevents blood clots from forming or growing, but it can also cause or worsen thrombocytopenia and bleeding.

Therefore, heparin is contraindicated for clients who have thrombocytopenia or are at risk of developing it. The other conditions are not contraindications to receiving heparin.

A. Maintain the affected extremity in a dependent position. B. Palpate the dorsalis pedis pulse. C. Wrap sterile gauze on the sharp point of the pins. D. Adjust the clamps on the fixator frame.

Correct Answer is B

Explanation

Palpating the dorsalis pedis pulse is an essential action to monitor for adequate circulation and perfusion in an extremity with an external fixator, which is a device that stabilizes and aligns fractured bones with metal pins and rods outside of the skin. The other options are incorrect because they could cause complications such as edema, infection, or malalignment.

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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?

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Naxlex Comprehensive Predictor Exams

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