The nurse assesses the patient's hand distal to the arterial line and notes cool, pale fingers with a capillary refill of 6 seconds. What could be the reason for these findings?
Normal capillary refill
Improper positioning of the hand
Excessive blood flow to the distal area
Inadequate blood flow distal to the arterial line.
The Correct Answer is D
A. A capillary refill time of 6 seconds is delayed (normal is <2-3 seconds).
B. Improper positioning could contribute but does not explain the sustained poor perfusion signs.
C. Excessive blood flow would cause warmth and redness, not coolness and pallor.
D. Cool, pale fingers with prolonged capillary refill indicate inadequate blood flow distal to the arterial line, possibly due to arterial occlusion or thrombosis. Immediate assessment and intervention are necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While arterial lines may reduce cuff-related discomfort, infection risk is not their primary benefit.
B. An arterial line provides direct, accurate, and continuous blood pressure monitoring, which is crucial for titrating IV blood pressure medications safely and effectively.
C. Patients with arterial lines generally require higher acuity monitoring, not lower.
D. Arterial lines do not improve the accuracy of non-invasive blood pressure measurements; they provide invasive, more precise data.
Correct Answer is A
Explanation
A. 16,800 mL is correct based on the formula.
The Parkland formula is:
4 mL × body weight (kg) × %TBSA burned
= 4 × 70 × 60
= 16,800 mL total fluid in 24 hours
B. 18,000 mL overestimates the requirement.
C. 14,000 mL underestimates the fluid needed.
D. 12,600 mL is too low for a 60% TBSA burn in a 70 kg patient.
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