The nurse determines that unlicensed assistive personnel (UAP) ...

[Coya19@aol.com]

The nurse determines that unlicensed assistive personnel (UAP) are not to be delegated client blood pressure measurements. What did the nurse observe to make this clinical decision?
 
  1. The valve on the bulb was closed.
  2. The client was sitting with the legs crossed.
  3. The arm was below the level of the heart.
  4. The UAP waited 2 minutes before re-measuring.
  5. The cuff bladder was placed over the brachial artery.

Question 2

A client comes to the emergency department with a temperature of 104F. Which assessment findings should the nurse use to determine if this client is experiencing heat stroke?
 
  1. Delirious
  2. Pale and dizzy
  3. Skin warm and flushed
  4. No evidence of sweating
  5. Had been playing tennis in the sun

[mcni194]

Answer to Question 1

Correct Answer: 2, 3

Rationale 1: The valve on the bulb needs to be closed to pump up the cuff.

Rationale 2: The adult client should be sitting with both feet on the floor. Crossed legs can cause elevations in systolic and diastolic blood pressures.

Rationale 3: The elbow should be slightly flexed with the palm of the hand facing up and the arm supported at heart level. The blood pressure increases when the arm is below heart level.

Rationale 4: After taking a measurement, 1 to 2 minutes should transpire before making any further measurements.

Rationale 5: The cuff should be placed evenly around the upper arm and the bladder center placed directly over the artery.

Answer to Question 2

Correct Answer: 1, 3, 4, 5

Rationale 1: Persons experiencing heat stroke may be delirious.

Rationale 2: Heat exhaustion is a result of excessive heat and dehydration. Signs of heat exhaustion include paleness and dizziness.

Rationale 3: Persons experiencing heat stroke generally have warm, flushed skin.

Rationale 4: Persons experiencing heat stroke often do not sweat.

Rationale 5: Persons experiencing heat stroke generally have been exercising in hot weather.

[Coya19@aol.com]

TYSM

[tuate]

Excellent