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 A
Explanation
The nurse should assess the client's gag reflex before allowing oral intake to prevent aspiration. The client's throat may be numb after a bronchoscopy, which is a procedure that uses a thin tube with a camera and light to examine the lungs and airways . The other actions are important but not the priority.
Correct Answer is A
Explanation
A high WBC count (leukocytosis) indicates an inflammatory response to an infection, such as pneumonia. The nurse should expect to see this value in a client who has pneumonia and monitor the client for signs and symptoms of sepsis or systemic inflammatory response syndrome (SIRS). The other values are within normal or expected ranges for a client who has pneumonia.
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