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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ensure that the infant's crib mattress is firm. A firm mattress reduces the risk of SIDS by preventing the infant from sinking into a soft surface, which can obstruct breathing.
B. Prop the infant with a pillow when in a side-lying position. Propping with a pillow is not recommended as it can increase the risk of suffocation and is not a recommended SIDS prevention measure.
C. Place the infant in a prone position whenever possible. Placing an infant in a prone (stomach) position is a significant risk factor for SIDS. Infants should be placed on their backs to sleep.
D. Swaddle the infant in a blanket for sleeping. While swaddling can be safe if done correctly, it is not as critical as ensuring a firm mattress. Additionally, improper swaddling can pose risks if the blanket becomes loose.
Correct Answer is ["A","B","C","E"]
Explanation
A. Ask if the client is experiencing any pain with urination. Urinary tract infections (UTIs) are common in older adults and can lead to sudden changes in behavior, including confusion and agitation.
B. Determine if the client has recently experienced a fall. Falls can lead to head injuries or other trauma that may cause confusion or changes in behavior in older adults.
C. Provide instruction on taking the client's temperature. Fever can be a sign of infection, which might be causing the sudden behavioral changes. Monitoring temperature can help identify if an infection is present.
D. Encourage increased intake of high protein foods. While good nutrition is important, it is not directly related to the sudden onset of confusion and agitation, making this a less immediate priority.
E. Review the client's current food and medication allergies. Allergic reactions to foods or
medications can cause sudden behavioral changes. Reviewing allergies can help determine if this is the cause of the symptoms.
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