The nurse would refrain from applying a blood pressure cuff on the affected arm of a patient who has a(n): (Select all that apply)
dialysis shunt.
2-year-old hand amputation.
previous mastectomy.
patent IV line.
Correct Answer : A,C
A. A dialysis shunt requires careful monitoring to avoid damaging the shunt, and blood pressure cuffs should not be applied to the arm with a shunt.
B. A hand amputation does not affect the use of the blood pressure cuff, but care should be taken with the affected area.
C. A previous mastectomy increases the risk of lymphedema, and using a blood pressure cuff on the affected arm could exacerbate this.
D. A patent IV line is not a contraindication for blood pressure measurement, but the nurse should take care not to interfere with the IV.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While understanding the onset of symptoms is important, the patient's occupation might provide more insight into potential environmental or work-related exposures that could explain the symptoms, such as chronic exposure to irritants or pollutants.
B. The occupation is highly relevant, as it may help identify occupational hazards, such as exposure to chemicals, dust, or other respiratory irritants, which could be contributing to the symptoms.
C. Although a headache could be related to fatigue or other symptoms, it is not the most relevant question in this case.
D. Abdominal pain is less likely to be the focus when the primary symptoms are chest congestion and a cough, which suggest respiratory involvement.
Correct Answer is C
Explanation
A. While pupil response can be an indicator of consciousness, the primary concern when assessing pupils is to check for signs of increased intracranial pressure, such as unequal pupil size.
B. The shape of the pupil is important to assess, but the concern here is typically more about the size and response to light, which can indicate a neurological issue.
C. Unequal pupil sizes (anisocoria) can indicate neurological problems, such as increased intracranial pressure or brain injury, and requires further evaluation.
D. Pupil size changes could indicate a variety of issues, but the focus should be on detecting unequal pupils, which can be a critical sign in head injury patients.
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