The practical nurse (PN) enters the room of a client who underwent a mastectomy eight hours ago. The PN observes the unlicensed assistive personnel (UAP) preparing to measure the client's blood pressure using an automated blood pressure device on the client's operative side. Which action should the PN implement?

Review the client's blood pressure as soon as the UAP records the measurement.

Instruct the UAP to measure the client's blood pressure on the non-operative side.

Ensure that the client's arm remains elevated after the blood pressure is recorded.

Advise the UAP to use a manual blood pressure cuff for a more accurate reading.

Answer and Explanation

The Correct Answer is B

A. Reviewing the blood pressure measurement is not the primary concern here; the issue is that the UAP is using the incorrect arm for the measurement.
B. The blood pressure should be measured on the non-operative side. Measuring on the operative side can cause discomfort, potential injury, or interfere with the healing process.
C. Elevating the arm after recording the blood pressure is not a standard requirement post-mastectomy. The immediate concern is the proper measurement site for the blood pressure.
D. A manual blood pressure cuff is not required for accuracy in this situation; the key issue is to use the non-operative arm for measurement.

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Correct Answer is B

Explanation

A. Eliminating citrus drinks is not specifically related to preventing dumping syndrome. While citrus drinks might irritate the stomach, the main dietary consideration for dumping syndrome is the timing of fluid intake.
B. Consuming fluids 30 minutes to one hour after meals helps prevent dumping syndrome. Drinking fluids too close to meal times can increase the risk of dumping syndrome by accelerating gastric emptying.
C. Increasing the intake of carbonated fluids after meals is not recommended for preventing dumping syndrome. Carbonated drinks can exacerbate symptoms rather than help prevent them.
D. Avoiding caffeinated beverages can be part of general dietary recommendations, but it is not the primary measure to prevent dumping syndrome. The timing of fluid intake relative to meals is more crucial.

A. Body temperature. B. Bowel sounds. C. Mental status. D. Skin integrity.

Correct Answer is C

Explanation

A. Body temperature is not directly relevant to the administration of zolpidem. Zolpidem is a sleep aid, so assessing body temperature is not necessary for this medication.
B. Bowel sounds are important for gastrointestinal assessments but are not related to the immediate considerations for zolpidem administration.
C. Assessing mental status is crucial before administering zolpidem because this medication can cause side effects like drowsiness, confusion, or impaired cognition. Ensuring the client’s mental status is appropriate helps prevent adverse effects.
D. Skin integrity is important for general health assessments but is not specifically relevant before administering a sleep aid like zolpidem.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is preparing a client for discharge after a gastric bypass. Prior to discharge, which information should the PN reinforce with the client to prevent dumping syndrome?

Correct Answer is B

Explanation

Before administering zolpidem at bedtime, which client assessment should the practical nurse (PN) complete?

Correct Answer is C

Explanation

A client receiving chemotherapy develops a cough that is productive of yellow-tinged sputum. After determining that the client is afebrile, which is the priority action for the practical nurse (PN) to take?

The practical nurse (PN) receives change of shift report on a postpartum unit. Which client should receive the PN's attention first?

In performing a focused assessment, the practical nurse (PN) lifts the client's skin as seen in the photo. Which should the PN do next?

During a nonstress test of a 38-week client, the practical nurse (PN) observes the fetal heart rate increases 15 beats above baseline lasting 10 seconds twice during a 20-minute tracing. Which finding should the PN document in the electronic medical record?

When the practical nurse (PN) prepares to transfer a 12-hour-old newborn from the birthing suite to the nursery, which question is most important for the PN to ask the mother?

The practical nurse (PN) is planning evening shift rounds for a group of postoperative clients who all had surgery earlier that day. Which client should the PN check first?

In administering nystatin suspension to the gums of an infant with a candida infection, which approach should the practical nurse (PN) use?

Exhibits Given the client's current treatment for fluid volume deficit, what condition(s) should the practical nurse (PN) monitor the client for? Select all that apply.