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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Allow the client to sign the consent with an X. The client has the right to give informed consent if they understand the procedure and its risks and benefits, even if they cannot read or write. The nurse should witness and document the client's signature with an X and verify their identity and understanding. The other options are not appropriate because they violate the client's autonomy and dignity.
Correct Answer is A
Explanation
Applying an ice pack to the client's knee can help reduce inflammation, swelling, and pain after a total knee arthroplasty. The nurse should avoid placing pillows under the client's knee, as this can cause flexion contractures and impair mobility and healing. Massaging or manipulating the incision site can increase pain and risk of infection or bleeding. Range-of-motion exercises are important for recovery, but they should be done with caution and under supervision, not when the client is experiencing severe pain.
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