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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
“I will discard unused pills after six months after replacing it with a new vial.” This statement indicates that the client understands that nitroglycerin tablets lose their potency over time and need to be replaced regularly.
Choice B is wrong because nitroglycerin can cause headaches as a side effect, but the client should not stop taking it if they have chest pain. They can use Tylenol for pain relief.
Choice C is wrong because nitroglycerin can cause hypotension and dizziness, so the client should avoid lying down or changing positions suddenly after taking it. They should sit or stand still until the chest pain subsides.
Choice D is wrong because a tingling feeling on the tongue is a normal sensation when taking sublingual nitroglycerin and does not indicate an adverse reaction. It also confirms that the tablet is potent and effective.
Correct Answer is A
Explanation
Insert a sterile needle and aspirate 3 to 5 mL of urine into the syringe. This is the best technique for obtaining a sterile urine specimen from an indwelling urinary catheter because it ensures that microorganisms in the specimen are from the urine, and not the result of contamination.
Choice B is wrong because it does not use sterile technique and it does not collect fresh urine. The urine in the drainage bag may have been sitting there for a long time and may not reflect the current condition of the patient’s urinary tract.
Choice C is wrong because it does not use sterile technique and it flushes the catheter with sterile water, which may dilute the urine and alter its composition.
Choice D is wrong because it does not use sterile technique and it collects urine from the drainage bag, which may be contaminated or stale.
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