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.

Answer and Explanation

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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Correct Answer is ["A","B"]

Explanation

- A: Correct. Broccoli is a vegetable that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.

- B: Correct. Yogurt is a dairy product that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.

- C: Incorrect. Pepperoni pizza contains pepperoni, cheese, and tomato sauce, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.

- D: Cream cheese is a dairy product that contains little or no tyramine and is therefore, safe in a client taking phenelzine.

- E: Incorrect. Bologna sandwich contains bologna, bread, and mayonnaise, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.

A. "I can keep a can of concentrated formula in the refrigerator for 3 days after I open it.” B. "I can dilute the ready-to-feed formula with water when my baby wants more than 4 ounces at a feeding.” C. "I should boil tap water for 2 minutes and cool it before I mix it with the powdered formula.” D. "I will be sure that all of my bottles contain BPA.”

Correct Answer is C

Explanation

Choice A rationale:

Keeping a can of concentrated formula in the refrigerator for 3 days after opening it is not safe. Once a can of formula is opened, it should be used within 24 hours and stored in the refrigerator. After 24 hours, any leftover formula should be discarded to prevent the risk of bacterial contamination.

Choice B rationale:

Diluting ready-to-feed formula with water is incorrect. Ready-to-feed formula is already prepared and does not need to be diluted further. Adding water to ready-to-feed formula can dilute its nutritional content and may not provide the necessary nutrients for the baby.

Choice C rationale:

Boiling tap water for 2 minutes and cooling it before mixing it with powdered formula is the correct method for safe formula preparation. Boiling the water kills harmful bacteria and ensures the formula is safe for the baby to consume. It is essential to cool the boiled water before mixing it with powdered formula to reach an appropriate feeding temperature.

Choice D rationale:

Ensuring that all bottles contain BPA (bisphenol A) is not a relevant consideration for formula preparation. BPA is a chemical that was previously used in some plastics, including baby bottles, but has been banned in baby bottles and sippy cups in several countries due to its potential health risks. Most modern baby bottles are BPA-free, and this statement does not address the safe handling and preparation of formula for the baby.

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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?

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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?