Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A client with a history of a right radical mastectomy arrives on the postoperative unit following surgical repair of a fractured left radius and application of a short arm cast. Which action should the practical nurse implement while obtaining the client's blood pressure (BP)?
A. Use a large cuff to obtain BP readings on either thigh.
Using a large cuff to obtain BP readings on either thigh is the appropriate action. With a history of a right radical mastectomy, blood pressure should not be taken on the right arm due to the risk of lymphedema. The left arm is also not suitable due to the recent surgery and cast. Therefore, the thigh is the best alternative site for accurate BP measurement.
B. Measure all vital signs every 2 hours except the BP.
Measuring all vital signs every 2 hours except the BP is not appropriate because BP is a critical vital sign that needs to be monitored regularly, especially in postoperative clients. Omitting BP measurements could miss important changes in the client's condition.
C. Obtain manual BP readings with a cuff on the left arm.
Obtaining manual BP readings with a cuff on the left arm is not recommended as the client has a recent surgical repair and cast on the left arm. This can cause discomfort and may not provide accurate readings.
D. Quickly release air from BP cuff on the right arm.
Quickly releasing air from the BP cuff on the right arm is not suitable due to the client's history of right radical mastectomy. This practice could exacerbate the risk of developing lymphedema in the affected arm.
This question is an excerpt from Nurse Dive's nursing test bank - HESI Speciality LPN Med Surg Proctored Exam. Take the full exam now
Full Explanation
Choice A reason: Using a large cuff to obtain BP readings on either thigh is the appropriate action. With a history of a right radical mastectomy, blood pressure should not be taken on the right arm due to the risk of lymphedema. The left arm is also not suitable due to the recent surgery and cast. Therefore, the thigh is the best alternative site for accurate BP measurement.
Choice B reason: Measuring all vital signs every 2 hours except the BP is not appropriate because BP is a critical vital sign that needs to be monitored regularly, especially in postoperative clients. Omitting BP measurements could miss important changes in the client's condition.
Choice C reason: Obtaining manual BP readings with a cuff on the left arm is not recommended as the client has a recent surgical repair and cast on the left arm. This can cause discomfort and may not provide accurate readings.
Choice D reason: Quickly releasing air from the BP cuff on the right arm is not suitable due to the client's history of right radical mastectomy. This practice could exacerbate the risk of developing lymphedema in the affected arm.
Similar Questions
A client with breast cancer who received chemotherapy two weeks ago returns to the clinic for follow-up. Which priority follow-up assessment should the practical nurse (PN) anticipate for this client?
A. Serum electrolytes.
While monitoring serum electrolytes is important, especially if the client is experiencing side effects such as vomiting or diarrhea, it is not the priority follow-up assessment. Chemotherapy can impact electrolytes, but blood cell counts are a more immediate concern.
B. Nutritional status.
Assessing nutritional status is important for overall health and recovery, but it is not the most critical follow-up assessment. Nutritional assessments can be addressed once more urgent concerns, such as blood cell counts, are evaluated.
C. Hydration status.
Hydration status is important, particularly if the client is experiencing side effects that lead to dehydration. However, hydration can usually be managed once the more critical assessment of blood cell counts has been completed.
D. Blood cell counts.
Blood cell counts are the priority follow-up assessment for a client who received chemotherapy. Chemotherapy can significantly impact the production of blood cells, leading to conditions such as anemia, neutropenia, or thrombocytopenia. Monitoring blood cell counts helps to identify these complications early and allows for appropriate interventions to be initiated.
Full Explanation
Choice A reason: While monitoring serum electrolytes is important, especially if the client is experiencing side effects such as vomiting or diarrhea, it is not the priority follow-up assessment. Chemotherapy can impact electrolytes, but blood cell counts are a more immediate concern.
Choice B reason: Assessing nutritional status is important for overall health and recovery, but it is not the most critical follow-up assessment. Nutritional assessments can be addressed once more urgent concerns, such as blood cell counts, are evaluated.
Choice C reason: Hydration status is important, particularly if the client is experiencing side effects that lead to dehydration. However, hydration can usually be managed once the more critical assessment of blood cell counts has been completed.
Choice D reason: Blood cell counts are the priority follow-up assessment for a client who received chemotherapy. Chemotherapy can significantly impact the production of blood cells, leading to conditions such as anemia, neutropenia, or thrombocytopenia. Monitoring blood cell counts helps to identify these complications early and allows for appropriate interventions to be initiated.
The practical nurse (PN) is assisting with blood pressure measurement for adults at a community health fair. Which blood pressure measurement requires the most immediate action by the PN?
A. 80/60 mm Hg.
A blood pressure measurement of 80/60 mm Hg is significantly low and may indicate hypotension, which can lead to symptoms such as dizziness, fainting, or shock. This requires immediate action to assess and manage the client's condition to prevent complications.
B. 140/90 mm Hg.
A blood pressure measurement of 140/90 mm Hg indicates hypertension, which is a concern but does not require immediate emergency intervention. It requires follow-up and management to prevent long-term health issues.
C. 130/85 mm Hg.
A blood pressure measurement of 130/85 mm Hg is considered elevated but not critically high. It is important to monitor and manage, but it does not require immediate emergency action.
D. 120/90 mm Hg.
A blood pressure measurement of 120/90 mm Hg is slightly elevated diastolic pressure but not critically so. It is important to monitor, but it does not necessitate immediate emergency intervention.
Full Explanation
Choice A reason: A blood pressure measurement of 80/60 mm Hg is significantly low and may indicate hypotension, which can lead to symptoms such as dizziness, fainting, or shock. This requires immediate action to assess and manage the client's condition to prevent complications.
Choice B reason: A blood pressure measurement of 140/90 mm Hg indicates hypertension, which is a concern but does not require immediate emergency intervention. It requires follow-up and management to prevent long-term health issues.
Choice C reason: A blood pressure measurement of 130/85 mm Hg is considered elevated but not critically high. It is important to monitor and manage, but it does not require immediate emergency action.
Choice D reason: A blood pressure measurement of 120/90 mm Hg is slightly elevated diastolic pressure but not critically so. It is important to monitor, but it does not necessitate immediate emergency intervention.
A female client with asthma arrives at the clinic with severe seasonal allergy congestion. On review of the client's current medication list, the practical nurse (PN) notices the client is taking tiotropium bromide and albuterol inhalation for asthma, as well as oral contraceptive ethinyl estradiol/norethindrone. The client receives new prescriptions for hydrocortisone and pseudoephedrine to treat the allergy symptoms. Which medication(s) should the PN reinforce as having the potential to increase the client's blood pressure?
A. Hydrocortisone.
Hydrocortisone is a corticosteroid that can cause fluid retention and increase blood pressure in some individuals. It is important for the PN to monitor the client's blood pressure and educate them about this potential side effect.
B. Tiotropium bromide.
Tiotropium bromide is a bronchodilator used to manage asthma and chronic obstructive pulmonary disease (COPD). While it is not commonly associated with increasing blood pressure, the PN should still be aware of any potential side effects and monitor the client's blood pressure.
C. Ethinyl estradiol/norethindrone.
Ethinyl estradiol/norethindrone is a combination oral contraceptive that contains estrogen and progestin. Estrogen can cause blood vessels to constrict, leading to an increase in blood pressure. The PN should educate the client about this potential side effect and monitor their blood pressure regularly.
D. Pseudoephedrine.
Pseudoephedrine is a decongestant that can cause vasoconstriction and increase blood pressure. It is important for the PN to inform the client about this potential side effect and monitor their blood pressure closely.
E. Albuterol sulfate.
Albuterol sulfate is a bronchodilator used to relieve asthma symptoms. While it can cause some cardiovascular side effects, such as increased heart rate, it is not typically associated with a significant increase in blood pressure. The PN should still monitor the client's blood pressure and be aware of any potential side effects.
Full Explanation
Choice A reason: Hydrocortisone is a corticosteroid that can cause fluid retention and increase blood pressure in some individuals. It is important for the PN to monitor the client's blood pressure and educate them about this potential side effect.
Choice B reason: Tiotropium bromide is a bronchodilator used to manage asthma and chronic obstructive pulmonary disease (COPD). While it is not commonly associated with increasing blood pressure, the PN should still be aware of any potential side effects and monitor the client's blood pressure.
Choice C reason: Ethinyl estradiol/norethindrone is a combination oral contraceptive that contains estrogen and progestin. Estrogen can cause blood vessels to constrict, leading to an increase in blood pressure. The PN should educate the client about this potential side effect and monitor their blood pressure regularly.
Choice D reason: Pseudoephedrine is a decongestant that can cause vasoconstriction and increase blood pressure. It is important for the PN to inform the client about this potential side effect and monitor their blood pressure closely.
Choice E reason: Albuterol sulfate is a bronchodilator used to relieve asthma symptoms. While it can cause some cardiovascular side effects, such as increased heart rate, it is not typically associated with a significant increase in blood pressure. The PN should still monitor the client's blood pressure and be aware of any potential side effects.