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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C,A,B,D
Explanation
Rationale
1. Pull the pinna of the ear in an upward and backward direction to straighten the ear canal.
2. Warm the irrigation solution to body temperature to prevent dizziness or discomfort.
3. Ask the client to tilt the head slightly toward the affected side to allow the solution to flow easily into the ear canal.
4. Position an emesis basin close to the neck under the ear to catch the returning solution and cerumen.
5. Direct the flow of the warm solution toward the wall of the ear canal, not directly at the eardrum, to dislodge the impacted cerumen gently
Correct Answer is D
Explanation
A. Exploring the client’s thoughts about dying is supportive but not the immediate priority when a specific request for a religious ritual is made.
B. Notifying the family of the request is a secondary action but should follow the immediate fulfillment of the client's request for spiritual support.
C. Suggesting that the hospital chaplain is available might be appropriate, but the client's specific request was for a priest, and it is better to offer to contact the priest directly.
D. Offering to contact the priest for the client directly addresses the client's immediate spiritual need and respects their request.
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