The ICU nurse identifies asystole on the patient's monitor. What is the initial action taken by the nurse?

Choice A rationale

Suction should never be applied during the insertion of the catheter because it can cause mucosal trauma, deplete the patient's oxygen reserves, and increase the risk of atelectasis. The catheter should be inserted with the suction turned off. Suction is only applied intermittently or continuously while withdrawing the catheter. The nurse must intervene to prevent injury to the tracheal wall and to ensure the patient maintains adequate oxygenation during the procedure.

Choice B rationale

Adjusting the wall suction to a range of 100 to 120 mm Hg is an appropriate and standard action for an adult patient. This level of pressure is sufficient to remove secretions without causing excessive damage to the delicate tracheal mucosa or causing significant lung collapse. Since this is a correct action, the RN does not need to intervene. The goal is to use the lowest effective pressure to clear the airway effectively.

Choice C rationale

Adding air to the tube or deflating the cuff during suctioning is an incorrect and dangerous practice. The cuff must remain inflated to provide a seal for mechanical ventilation and to protect the airway from the aspiration of subglottic secretions. Deflating the cuff could cause the patient to lose tidal volume or inhale oral contaminants. The RN must intervene to ensure the cuff integrity is maintained and the patient's ventilation is not compromised.

Choice D rationale

Hyperoxygenating the patient with 100 percent oxygen for at least 30 to 60 seconds before suctioning is a standard nursing intervention. Suctioning inherently removes oxygen from the airways along with secretions, which can lead to hypoxemia and cardiac arrhythmias. By providing extra oxygen beforehand, the student helps maintain the patient's oxygen saturation levels. This is a correct clinical behavior, so no intervention from the RN is required in this instance.

Choice E rationale

Inserting the catheter until resistance is met can cause significant trauma to the carina and trigger a violent cough reflex or bronchospasm. Current evidence-based guidelines recommend "shallow suctioning," where the catheter is inserted only to a predetermined length or just past the end of the ET tube. The RN should intervene to teach the student to avoid hitting the carina, thereby reducing the risk of tissue damage and patient discomfort during the procedure.

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.