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 B
Explanation
A. Changing gloves is important for infection control, but in this context, the main issue is with the technique being used for the client's feet.
B. Soaking the feet is not recommended for clients with diabetes due to the risk of skin damage and infection; it is better to wash the feet gently and inspect them regularly.
C. Checking the client’s feet is important but should be done before washing or soaking, and the main concern here is not to soak the feet at all.
D. While testing water temperature is crucial for safe bathing, the more pressing issue here is the method of foot care for a diabetic client, which is not to soak the feet
Correct Answer is A
Explanation
A. Based on the understanding of 90-90 skeletal traction and the common complications associated with pin sites, the practical nurse should focus on assessing the areas around the pin insertion sites in the femur and possibly the tibia for any signs of inflammation.
B. the back is not the correct location
C. The sole of the foot is not the correct location
D. The unaffected limb is not the appropriate location.
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