Which action should the nurse take first when the low pressure alarm sounds for a patient who has an arterial line in the left radial artery?
Re-zero the monitoring equipment.
Check the left hand for pallor.
Fast flush the arterial line.
Assess for dysrhythmias
The Correct Answer is B
B. Checking the left hand for pallor can help assess peripheral perfusion and determine if there is adequate blood flow distal to the arterial line insertion site. Pallor in the left hand could indicate decreased perfusion, which may contribute to the low-pressure alarm.
A. Re-zeroing the monitoring equipment may be necessary to ensure accurate pressure readings. However, it should not be the first action taken when the low-pressure alarm sounds. Before re-zeroing, the nurse should assess the patient's condition to ensure there are no immediate issues affecting arterial pressure.
C. Fast flushing the arterial line is not typically the first action to take when the low-pressure alarm sounds. Fast flushing may increase the risk of dislodging the catheter or causing air embolism if there is a problem with the line.
D. Assessing for dysrhythmias should be part of the overall assessment but may not be the first action taken in response to the alarm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. its use in hypovolemic shock is generally not appropriate because the primary treatment for hypovolemic shock is fluid resuscitation to address the volume loss.
A. Dopamine is often used in neurogenic shock to increase systemic vascular resistance and improve blood pressure. Therefore, dopamine is an appropriate choice for the management of hypotension due to neurogenic shock.
B. Dopamine is commonly used in septic shock to improve cardiac output and systemic vascular resistance. It helps to support blood pressure and perfusion in septic shock patients.
D. It is indicated for cardiogenic shock as it increases cardiac contractility.
Correct Answer is ["B","C","D","E","F"]
Explanation
B. Continuous monitoring of vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, is essential for assessing the patient's hemodynamic status and response to treatment.
Additionally, continuous electrocardiographic (ECG) monitoring allows for real-time assessment of cardiac rhythm and conduction abnormalities.
C. This is an important nursing action to provide comfort and reduce anxiety for the patient. Transcutaneous pacing is often used as a temporary measure to stabilize heart rate and cardiac output until more definitive treatment, such as insertion of a permanent pacemaker, can be performed.
D. Atropine is another medication commonly used in ACLS protocols for symptomatic bradycardia and heart block. It acts to increase heart rate by blocking vagal tone. However, its effectiveness in third- degree heart block may be limited, and transcutaneous pacing is often the preferred intervention in this situation.
E. Correct placement of transcutaneous pacemaker pads is crucial for effective pacing. The pads should be placed on the chest over the heart to deliver electrical impulses and stimulate myocardial contraction. Proper placement ensures optimal pacing effectiveness and patient safety.
F. This nursing action addresses the patient's comfort and pain management following the placement of the transcutaneous pacemaker. The procedure may cause discomfort or pain, and appropriate analgesia should be provided to alleviate any discomfort and promote patient comfort.
A. Epinephrine is a medication commonly used in advanced cardiac life support (ACLS) protocols for bradycardia and heart block. In this scenario, the patient's heart rate has decreased to 40 beats/minute, indicating symptomatic bradycardia and potential hemodynamic instability. Epinephrine may be administered to increase heart rate and improve cardiac output.
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