The nurse observes the unlicensed assistive personnel (UAP) obtain vital signs on four adult clients.
For which client should the nurse intervene to redirect to use of proper method?
Using automatic BP cuff with shivering client with history of an irregular heart rate.
Pulling the client’s ear pinna backward, up and out to obtain a tympanic membrane temperature.
Counting the client’s radial pulse who is supine with the forearm straight alongside the body.
Counting the respirations for one full minute for a client with tachypnea.
The Correct Answer is A
Using an automatic BP cuff with a shivering client with a history of an irregular heart rate can result in inaccurate and low readings.
This is because shivering can interfere with the cuff inflation and deflation, and an irregular heart rate can affect the accuracy of the device.
The nurse should intervene and use a manual BP cuff with a stethoscope instead.
Choice B is wrong because pulling the client’s ear pinna backward, up and out to obtain a tympanic membrane temperature is the correct technique for adults and older children. This helps to straighten the ear canal and allow the light to reflect on the tympanic membrane, which shares the same vascular artery as the hypothalamus.
Choice C is wrong because counting the client’s radial pulse who is supine with the forearm straight alongside the body is an appropriate method.
The radial pulse can be easily palpated at the wrist, and the supine position and straight forearm do not affect the pulse rate.
Choice D is wrong because counting the respirations for one full minute for a client with tachypnea is a recommended practice.
Tachypnea means rapid breathing, and counting for one full minute can ensure accuracy and detect any variations in the respiratory pattern.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Self-determination. Self-determination is the ethical principle that respects the right of a person to make their own decisions. When a nurse respects the decision of a client who refuses a blood transfusion, the nurse is upholding this principle by acknowledging and protecting the client’s autonomy.
Choice A is wrong because beneficence is the ethical principle that involves actively seeking benefits or the promotion of good.
While a blood transfusion may be beneficial for the client, it is not the nurse’s role to impose their own judgment on the client’s choice.
Choice C is wrong because justice is the ethical principle that involves fairness and the just distribution of resources.
A blood transfusion is not a scarce resource that needs to be allocated among competing demands.
Choice D is wrong because fidelity is the ethical principle that involves keeping promises and being faithful to one’s commitments.
A blood transfusion is not a promise or a commitment that the nurse has made to the client.
Correct Answer is B
Explanation
This is because non-steroidal anti-inflammatory drugs (NSAIDs) are medicines that are used to treat rheumatoid arthritis by reducing pain, inflammation, and swelling.
However, NSAIDs do not slow down the disease progression or prevent joint
damage. Therefore, they are often used along with other types of medications, such as methotrexate or biologics, that can modify the disease course. NSAIDs may take up to two weeks to reach their full anti-inflammatory effect.
Choice A is wrong because using aspirin to relieve other types of pain can increase the risk of bleeding and stomach ulcers when taken with NSAIDs.
Choice C is wrong because taking the medication on an empty stomach can increase the risk of stomach irritation and ulcers.
Choice D is wrong because taking the medication after exercising does not prevent the progression of disease or joint damage.
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