The nurse is caring for a client diagnosed with breast cancer who ...

[gonzo233]

The nurse is caring for a client diagnosed with breast cancer who underwent a left-sided mastectomy two days prior.
 
  The nurse has delegated vital signs on this client to the unlicensed assistive personnel (UAP). What specific instructions should the nurse provide to the (UAP) in delegating this task?
  1. Take the blood pressure on the right arm.
  2. No special instructions are needed.
  3. Take the blood pressure on the left arm.
  4. Take the blood pressure on both arms for a baseline.

Question 2

The nurse is assessing an older adult client with arteriosclerosis and obtains a blood pressure reading of 172/98 mmHg. Which factors may be applicable in this situation?
 
  Select all that apply.
  1. Arteriosclerosis decreases the ventricular force necessary for ejection of blood.
  2. Arteriosclerosis increases blood vessel elasticity.
  3. Arteriosclerosis decreases blood vessel compliance.
  4. Age decreases blood vessel elasticity.
  5. Arteriosclerosis plays no role in the blood pressure of this client.

[xiaomengxian]

Answer to Question 1

Correct Answer: 1

The blood pressure should be taken in the arm opposite the surgical site. Blood pressures should not be taken on the same side as a mastectomy. It should also not be taken on an arm with a shunt, trauma, or disease. If this is not possible, then a thigh pressure should be obtained. The nurse should be sure to provide the PCA with instructions to use the arm opposite the surgical site for blood pressure readings. The left arm should not be used for blood pressure readings, intravenous fluids, or other invasive procedures. It is not possible to take the blood pressure using both arms, since the left arm should never be used again for blood pressure readings. If bilateral readings become necessary, the thighs should be used so that a comparison can be made.

Answer to Question 2

Correct Answer: 3, 4
Arteriosclerosis results in hardened and rigid arteries, which are less compliant. Elasticity of blood vessels decreases with age and also leads to increased blood pressure. Arteriosclerosis requires greater ventricular force and leads to increased blood pressure. Arteriosclerosis decreases the elasticity of the arteries. Arteriosclerosis has a direct effect on blood pressure; decreased elasticity and compliance is directly related to the increase in blood pressure.

[gonzo233]

Gracias!

[tkempin]

TYSM