A nurse is caring for a patient with a right radial arterial line. Which action should the nurse take?
Ensure the pressure bag around the flush solution is inflated to 300 mm Hg.
Flush the line before administering antibiotics.
Instruct the patient to bear down when readings are obtained.
Position the patient in Trendelenburg to obtain readings.
The Correct Answer is A
Choice A rationale
To ensure a continuous flow of flush solution through the arterial catheter and prevent blood from backing up into the tubing, the pressure bag must be maintained at 300 mm Hg. This high pressure overcomes the patient's arterial pressure, which normally ranges from 100 to 140 mm Hg systolic. This constant flow of approximately 3 mL per hour maintains patency of the line and prevents clot formation at the catheter tip, ensuring accurate readings.
Choice B rationale
An arterial line is strictly used for hemodynamic monitoring and arterial blood gas sampling, not for the administration of medications or intravenous fluids. Injecting antibiotics or other drugs into an arterial line can cause severe vasospasm, arterial occlusion, and potential tissue necrosis or gangrene in the distal limb. All intravenous medications must be administered through a venous access device, such as a peripheral IV or a central venous catheter, to ensure systemic distribution.
Choice C rationale
Bearing down, or the Valsalva maneuver, increases intra-thoracic and intra-abdominal pressure, which temporarily alters venous return and blood pressure readings. This would result in inaccurate hemodynamic data, as the arterial line is meant to measure the patient's physiological baseline or response to therapy. The patient should remain quiet and still in a supine or semi-Fowler's position with the transducer leveled at the phlebostatic axis to obtain the most reliable and consistent blood pressure measurements.
Choice D rationale
The Trendelenburg position, where the head is lower than the feet, is used to increase venous return or during certain central line insertions, but it is not appropriate for obtaining arterial line readings. Hemodynamic measurements should be taken with the patient in a neutral position. The transducer must be leveled at the phlebostatic axis, which is the fourth intercostal space at the mid-axillary line, to ensure the hydrostatic pressure does not skew the recorded blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["8"]
Explanation
Step 1 is 80 kg × 5 mg/kg = 400 mg.
Step 2 is 400 mg ÷ (150 mg ÷ 3 mL) = 8 mL. Final calculated answer is 8 mL.
Correct Answer is D
Explanation
Choice D rationale
To ensure the accuracy of the hemodynamic data from a radial arterial line, the nurse must reference and zero the system. Referencing involves positioning the transducer at the phlebostatic axis, which is the level of the atria at the fourth intercostal space, mid-axillary line. Zeroing the line negates the effects of atmospheric pressure on the monitoring system. This ensures that the pressure displayed on the monitor represents only the patient's internal physiological blood pressure, preventing false high or low readings.
Choice A rationale
Flushing the arterial line is done to maintain patency of the catheter and clear the tubing of blood after sampling. However, a continuous flush system usually handles this at a rate of 3 mL per hour. Manually flushing for 10 seconds is not a standard requirement prior to taking a reading and could potentially cause a fluid bolus or damage the artery if done with excessive force. It does not contribute to the calibration or accuracy of the electronic pressure transducer.
Choice B rationale
While positioning is important, the correct landmark for hemodynamic monitoring is the phlebostatic axis, not the sternal angle. The sternal angle, or Angle of Louis, is used as a landmark for identifying the second rib and auscultating heart sounds, but it does not correspond to the level of the heart's chambers for pressure monitoring. Using the incorrect reference point will lead to hydrostatic pressure errors, where every inch the transducer is below the heart adds approximately 2 mmHg to the reading.
Choice C rationale
The Allen test is a diagnostic physical exam used to assess the patency of the ulnar artery and the adequacy of collateral circulation to the hand. This must be performed before the arterial line is even inserted into the radial artery to ensure that the hand will remain perfused if the radial artery becomes occluded. Once the line is already in place, performing an Allen test is not a prerequisite for obtaining a routine pressure reading from the monitor.
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