The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?

Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed.

Advise the UAP to document the last blood pressure obtained on the client's graphic sheet.

Estimate the blood pressure by assessing the pulse volume of the client's radial pulses.

Document why the blood pressure cannot be accurately measured at the present time.

Answer and Explanation

The Correct Answer is C

A. Demonstrating how to palpate the popliteal pulse is not a suitable alternative for measuring blood pressure when the client cannot be measured in the arms or legs. Palpating peripheral pulses does not provide accurate blood pressure measurements.

B. Advising the UAP to document the last blood pressure obtained is insufficient because it does not address the need for current blood pressure monitoring. Documentation of past
measurements does not provide real-time information about the client's hemodynamic status.

C. Estimating the blood pressure by assessing the pulse volume of the client's radial pulses is a reasonable alternative when traditional blood pressure measurement sites are inaccessible. Although not as accurate as traditional methods, assessing the strength of peripheral pulses can provide valuable information about perfusion and blood pressure status.

D. Documenting why the blood pressure cannot be accurately measured is important for record- keeping but does not address the need for ongoing blood pressure monitoring or provide an alternative method for assessment.

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Correct Answer is B

Explanation

A. Gained 10 lb (4.5 kg) within one month. Weight gain is not typically associated with the onset of type 1 diabetes. In fact, weight loss is more common due to the body's inability to use glucose properly.
B. Drinks more fluids than previously. Increased thirst (polydipsia) is a classic symptom of type 1 diabetes due to high blood sugar levels causing dehydration.
C. Voids only one or two times per day. Increased urination (polyuria) is a common symptom of type 1 diabetes as the body attempts to excrete excess glucose, so decreased urination is unlikely.
D. Refuses to eat favorite meals at home. While changes in appetite can occur, it is not a primary symptom of type 1 diabetes. Increased hunger (polyphagia) is more typical.

Correct Answer is ["18"]

Explanation

First, we need to find the concentration of Heparin per milliliter in the current infusion. We can do this by dividing the total number of Heparin units by the total volume of the infusion:

Heparin concentration (units/mL) = Total Heparin units / Total volume (mL) Heparin concentration = 25,000 units / 500 mL

Heparin concentration = 50 units/mL

Now, we know the desired rate of Heparin delivery (900 units/hour) and the concentration of Heparin per milliliter (50 units/mL). We can use this information to calculate the required flow rate in milliliters per hour:

Flow rate (mL/hour) = Desired Heparin rate (units/hour) / Heparin concentration (units/mL)

Flow rate = 900 units/hour / 50 units/mL Flow rate = 18 mL/hour

Therefore, the nurse should set the infusion pump to deliver 18 mL/hour.

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The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A school-aged client was recently diagnosed with type 1 diabetes mellitus. Which symptom did the client's parents most likely report?

Correct Answer is B

Explanation

Correct Answer is ["18"]

Explanation

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