The nurse assesses a client postoperatively who has an arterial line in the right radial artery. Assessment findings include pallor, paresthesia, and slow capillary refill in the client's right-hand fingers. Which action should the nurse take?
Perform the Allen test.
Elevate the client's right arm.
Flush the line with heparinized saline.
Notify the healthcare provider.
The Correct Answer is D
A. Perform the Allen test. The Allen test is performed before inserting a radial arterial line to assess ulnar artery patency and ensure adequate collateral circulation. Since the arterial line is already placed and the client is showing signs of compromised circulation (pallor, paresthesia, and slow capillary refill), immediate intervention is required rather than further pre-insertion testing.
B. Elevate the client's right arm. Elevating the arm does not directly resolve arterial compromise and may further reduce perfusion by impairing arterial blood flow. The priority is to assess and address potential ischemia caused by arterial line complications.
C. Flush the line with heparinized saline. Flushing an arterial line is appropriate for maintaining patency, but in this case, it may worsen ischemia if the catheter is causing an obstruction or arterial spasm. Additionally, flushing should never be done forcefully due to the risk of embolization.
D. Notify the healthcare provider. The pallor, paresthesia, and delayed capillary refill suggest arterial insufficiency, possible thrombosis, or arterial spasm, which can lead to tissue ischemia and necrosis if not addressed promptly. The healthcare provider should be notified immediately to assess the need for interventions such as removal of the arterial line, vascular assessment, or anticoagulation therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
- I will monitor my urine output and pay attention to the volume and color. Clients with DI must monitor urine output closely because polyuria and diluted urine indicate under-treatment, while sudden reduced output and darker urine may suggest fluid retention or excessive desmopressin dosing.
- I will always wear my medical alert bracelet. A medical alert bracelet is essential for emergency situations since DI can lead to severe dehydration and electrolyte imbalances if left untreated. It ensures that emergency responders are aware of the condition if the client is unable to communicate.
- I will use the same scale and wear a similar amount of clothing when I take my weekly weight. Monitoring body weight trends is crucial in DI management, as sudden weight gain may indicate fluid retention (over-treatment), while weight loss may suggest dehydration. Using a consistent method ensures accurate tracking.
- If I gain more than 2.2 lb (1 kg), I will go to the emergency department (ED). A sudden weight gain may suggest fluid retention from over-treatment, but mild fluctuations are not always an emergency. Instead, the client should report significant weight changes to their healthcare provider to assess medication adjustments.
- If I become thirstier, I may need another dose of the medication. While increased thirst may indicate under-treatment, self-adjusting the desmopressin dose is not recommended without consulting a healthcare provider. The client should track symptoms and report persistent thirst to determine if a dosage change is necessary.
Correct Answer is ["A","B","C","D"]
Explanation
A. Allow the family to touch and talk to the client. Family presence can provide emotional support for both the client and loved ones. Even though the client is sedated and has a low GCS, familiar voices and touch may reduce stress and anxiety. Allowing family interaction fosters comfort and connection during a critical time.
B. Reassess the client's vascular access. Maintaining secure and functional vascular access is essential for administering fluids, medications, and emergency interventions. Before transport, the nurse should confirm IV patency, ensure secure connections, and assess for signs of infiltration or malfunction. Trauma patients may require additional or larger bore IV access for fluid resuscitation or transfusion.
C. Assess neurological vital signs every 15 minutes. Frequent neurological assessments are crucial in head trauma patients with a low GCS to monitor for signs of worsening intracranial pressure, cerebral edema, or herniation. Changes in pupil response, motor function, or vital signs may indicate neurological deterioration requiring urgent intervention. Monitoring trends over time is necessary for early detection of complications.
D. Administer ophthalmic ointment. Clients with a low GCS often have impaired blinking, placing them at risk for corneal abrasions and dryness. Applying ophthalmic lubricant or artificial tears protects the cornea from injury and promotes eye health. Preventing exposure keratitis is essential in unconscious or sedated clients to avoid long-term ocular damage.
E. Apply soft bilateral wrist restraints for transport. Restraints are unnecessary because the client is sedated, intubated, and has a GCS of 6, meaning they cannot attempt self-extubation or interfere with care. Restraints should only be used if the client demonstrates a risk of harm. Standard transport protocols prioritize sedation and safety measures over restraints unless specifically required.
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