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 A

Explanation

A. Folic acid deficiency is the most significant maternal factor associated with the development of spina bifida occulta. Adequate folic acid intake before and during pregnancy is crucial for preventing neural tube defects.
B. Preeclampsia is a serious pregnancy complication but does not have a direct link to spina bifida occulta compared to the impact of folic acid deficiency.
C. A short interval between pregnancies is associated with other risks but is not a known direct cause of spina bifida occulta.
D. Tobacco use has various adverse effects on pregnancy and fetal development but is not as directly linked to the risk of spina bifida occulta as folic acid deficiency.

A. A same-sex partner who broke her arm during a volleyball game. B. A 3-year-old with multiple old fractures of the arms and torso. C. A married man with multiple bruises to his hands and face. D. A homeless man whose clothing is soiled and has a foul-smelling body odor. E. An older adult with a skull fracture that occurred in an automobile collision.

Correct Answer is ["B","C"]

Explanation

A. A broken arm from a volleyball game is an injury that is not necessarily indicative of family violence; it appears to be an accident.
B. Multiple old fractures in a young child may indicate possible abuse or family violence, as this pattern is concerning for potential neglect or physical harm.
C. Multiple bruises on the hands and face of a married man may suggest a pattern of domestic violence, which should be reported for further assessment.
D. Soiled clothing and foul body odor may indicate poor living conditions but are not specific indicators of family violence.
E. A skull fracture from an automobile collision is likely an accident, not necessarily indicative of family violence unless further evidence suggests abuse.

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Naxlex Comprehensive Predictor Exams

A newborn's assessment reveals spina bifida occulta. Which maternal factor should the practical nurse (PN) identify as having the greatest impact on the development of this newborn complication?

Correct Answer is A

Explanation

The practical nurse (PN) is assisting with data collection for clients who have been admitted to the emergency department. What clients should the PN report to the nurse for further intervention for possible family violence? Select all that apply.

Correct Answer is ["B","C"]

Explanation

An older adult client returns to the clinic for a follow-up visit with the healthcare provider for management of depression related to the death of a child, who was killed 6 months ago by a drunk driver. Which finding indicates to the practical nurse (PN) that the client is improving?

Exhibits The practical nurse (PN) performs a focused assessment and documents it in the computer. Select what items require immediate follow-up by the PN. Select all that apply.

The practical nurse (PN) is assessing an older adult client with left-sided heart failure (HF). Which intervention is most important for the PN to implement?

A female client who has been taking oral contraceptives for the past year comes into the clinic for an annual exam. Which finding is most important for the practical nurse (PN) to report to the healthcare provider?

Exhibits Review H and P, nurse's note, laboratory results, prescriptions, and imaging studies. What complications should the practical nurse (PN) monitor for in the next 6 to 8 hours? Select all that apply.

A client who had a knee replacement surgery receives a prescription for enoxaparin 30 mg subcutaneously every 12 hours for 10 days. The medication is available in 30 mg per 0.3 mL prefilled syringes. How many mL should the practical nurse (PN) administer each day? (Enter numerical value only.)