A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients.
The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients?
A client who had blood drawn from the right antecubital area 1 hr ago.
A client who has a right peripherally inserted central catheter.
A client who had dialysis and is using an arteriovenous shunt in the left lower forearm.
A client who had a right hemisphere stroke.
The Correct Answer is B
Choice A rationale:
A client who had blood drawn from the right antecubital area 1 hour ago does not require blood pressure measurement from the left arm. Blood drawing from one arm does not affect the accuracy of blood pressure measurement in the opposite arm.
Choice B rationale:
A client who has a right peripherally inserted central catheter (PICC) line should have blood pressure measured from the opposite arm to avoid disrupting the PICC line.
Choice C rationale:
A client who had dialysis and is using an arteriovenous shunt in the left lower forearm should have blood pressure measured from the opposite arm. Using the arm with an arteriovenous shunt for blood pressure measurement can lead to inaccurate readings and potentially damage the shunt, disrupting the client's dialysis treatment.
Choice D rationale:
A client who had a right hemisphere stroke does not necessarily require blood pressure measurement from the left arm. Stroke location does not impact the choice of the arm for blood pressure measurement; other factors, such as vascular access devices or medical procedures, are more relevant in this context.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Telling the client, "It's not your choice to be here, so you have to accept the treatment we plan for you," disregards the client's autonomy and right to make decisions about their own healthcare. In mental health settings, respecting a patient's autonomy and involving them in the decision-making process is crucial for ethical care. This statement does not address the client's fear or provide any reassurance.
Choice B rationale:
Choice C rationale:
Asking, "Why do you think your provider will prescribe you medications that will make you sleep?" attempts to explore the client's fear, but it may come across as dismissive or invalidating. It could make the client feel unheard or misunderstood, which is not ideal in this situation.
Choice D rationale:
Stating, "I will make sure that we respect your right to refuse medications," is the most appropriate response. It acknowledges the client's fear and reassures them that their autonomy will be respected. It opens the door for a discussion about the client's concerns, allowing them to express their fears and preferences. Respecting the client's right to refuse medications is fundamental to ethical nursing practice and patient-centered care.
Correct Answer is B
Explanation
- A. Adjust the crutches for comfort as needed. This is incorrect because the crutches should be adjusted to fit the client's height and arm length, and should not be changed without proper guidance.
- B. Use a three-point gait. This is correct because this gait allows the client to avoid putting weight on the affected leg and maintain balance and stability.
- C. Wear leather-soled shoes. This is incorrect because leather-soled shoes can be slippery and increase the risk of falls and injuries.
- D. Advance the affected leg first when walking upstairs. This is incorrect because the client should advance the unaffected leg first when walking upstairs, and the affected leg first when walking downstairs.
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