When assessing for adequate circulation prior to inserting an arterial line, the nurse should perform which of the following actions?
Check for capillary refill by Performing an Allen test
Assess blood pressure in both arms
Monitor heart rate and rhythm
Evaluate oxygen saturation levels
The Correct Answer is A
A. The Allen test assesses collateral circulation to the hand by evaluating blood flow through the ulnar artery before cannulating the radial artery for an arterial line, ensuring adequate circulation.
B. Blood pressure assessment is important but does not specifically evaluate collateral circulation at the insertion site.
C. Monitoring heart rate and rhythm is vital for overall cardiovascular status but unrelated to local circulation for arterial line placement.
D. Oxygen saturation reflects respiratory function, not the adequacy of circulation at the insertion site.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Inserting a urinary catheter is important for monitoring output but not the immediate priority.
B. Maintaining the airway is the top priority in burn patients, especially with burns involving the chest and upper body, due to the risk of airway edema and inhalation injury that can rapidly compromise breathing.
C. Pain management is essential but comes after securing airway and circulation.
D. Fluid resuscitation is critical during the resuscitation phase but airway management takes precedence to ensure oxygenation.
Correct Answer is D
Explanation
A. Infection is a significant concern in burn clients but is not the immediate life-threatening priority in the initial phase of care.
B. Fluid imbalance is a critical issue during burn management, especially in the resuscitation phase, but airway management takes precedence.
C. Paralytic ileus can occur due to stress and decreased perfusion but is a lower priority compared to airway compromise.
D. Airway obstruction is the top priority in clients with burns to the head, neck, and chest, due to the risk of inhalation injury, swelling, and respiratory compromise. Airway patency must be ensured immediately to prevent life-threatening complications.
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