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 D
Explanation
A. Inserting a urinary catheter is important for monitoring fluid status but is not the immediate priority.
B. Drawing blood for labs is necessary but not the first concern in a potentially life-threatening situation.
C. Pain management is important, but airway assessment takes precedence.
D. Inspecting the mouth for signs of inhalation injury is the priority because facial burns increase the risk of airway compromise. Airway management is the first priority in emergency burn care to prevent respiratory failure.
Correct Answer is D
Explanation
A. Each suction pass should be limited to 10-15 seconds to minimize hypoxia and trauma, not 25 seconds.
B. Suctioning should generally be limited to 2-3 passes per session to reduce airway irritation and hypoxia.
C. Suction should only be applied when withdrawing the catheter, not while advancing it, to prevent mucosal damage and hypoxia.
D. Preoxygenating the client with 100% oxygen for 30 seconds to 3 minutes before suctioning helps prevent hypoxemia during the procedure, especially important in clients with COPD and artificial airways.
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