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 ["100"]
Explanation
- Total volume of the infusion: 50 mL (saline bag)
- Infusion time: 30 minutes = 0.5 hours (convert minutes to hours)
- We don't need the concentration of gentamicin for this calculation because we're only interested in the total volume delivered per hour.
- Flow rate: Since all the medication is delivered within the infusion time, the flow rate is equal to the total volume divided by the infusion time.
Flow rate (mL/hour) = Total volume (mL) / Infusion time (hours)
Flow rate = 50 mL / 0.5 hours Flow rate = 100.0 mL/hour
Therefore, the nurse should set the pump to deliver 100.0 mL/hour to infuse the 60 mg of gentamicin over 30 minutes.
Correct Answer is B
Explanation
A. Lymphangitis is characterized by inflammation of the lymphatic vessels and is often associated with red streaks and tenderness. The absence of inflammation and tenderness suggests a different etiology.
B. Malignancy is suggested by the presence of a large, nontender, hardened lymph node. These characteristics are commonly associated with metastatic spread of cancer to the lymph nodes. Further diagnostic testing, such as biopsy, would be warranted to confirm malignancy.
C. Viral infection may cause lymphadenopathy, but typically, the lymph nodes are tender and may be enlarged but not necessarily hardened. The absence of tenderness and the hardened consistency of the lymph node suggest a different etiology.
D. Bacterial infection can cause lymphadenopathy, which may be tender and enlarged, but the nontender, hardened nature of the lymph node in this case is more indicative of malignancy
rather than a bacterial infection.
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