After the nurse obtains a blood sample from a client's right radial arterial client reports a sudden onset of pain at the arterial line insertion site. The nurse recognizes which physiological effect may be inducing the sudden pain?
Elevation in blood pressure.
Vasospasm at insertion site.
Clot in the arterial catheter.
Air lock in the transducer.
The Correct Answer is B
A) Elevation in blood pressure:
While elevation in blood pressure could potentially cause discomfort at the arterial line insertion site, it is not the most likely physiological effect to induce sudden pain in this scenario. Blood pressure elevation would typically cause generalized symptoms rather than localized pain at the insertion site.
B) Vasospasm at insertion site:
Correct. Vasospasm refers to the sudden constriction of blood vessels, leading to reduced blood flow. It can occur in response to arterial puncture or manipulation during arterial line insertion, resulting in sudden pain at the insertion site.
C) Clot in the arterial catheter:
A clot in the arterial catheter could potentially cause obstruction and affect blood flow, but it is less likely to induce sudden pain at the insertion site unless there is associated ischemia or tissue damage.
D) Air lock in the transducer:
An air lock in the transducer could disrupt pressure monitoring but is not typically associated with sudden pain at the insertion site. It may lead to inaccurate pressure readings rather than localized pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Renal calculi, also known as kidney stones, are solid masses made up of crystals that form in the kidneys due to various factors, including supersaturation of urine with stone-forming substances, inadequate urine volume, and conditions that promote crystal precipitation and retention in the urinary tract. Here's the breakdown of the pathological process contributing to the client's clinical presentation:
A) Excessive urine output:
Excessive urine output (polyuria) is not typically associated with the formation of renal calculi. In fact, low urine output (oliguria) or concentrated urine may increase the risk of stone formation by reducing the volume of urine available to dilute stone-forming substances.
B) Excessive fluid intake:
Excessive fluid intake is generally beneficial in preventing kidney stone formation by increasing urine volume and diluting stone-forming substances. Therefore, it is not likely to contribute to the development of renal calculi in this scenario.
C) Increased calcium reabsorption:
Correct. Increased calcium reabsorption in the renal tubules can lead to hypercalcemia and hypercalciuria, which are risk factors for the formation of calcium-containing kidney stones (calcium oxalate or calcium phosphate stones). Excessive calcium reabsorption may occur due to various factors, including hormonal imbalances (e.g., hyperparathyroidism) or medications that affect calcium metabolism.
D) Increased serum alkalinity:
Increased serum alkalinity (alkalosis) is not typically associated with the formation of renal calculi. Urinary pH may influence the formation of certain types of kidney stones (e.g., uric acid stones are more likely to form in acidic urine), but alkalosis alone is not a primary factor in stone formation.
Correct Answer is D
Explanation
A) Shivering:
Shivering is not a normal inflammatory response to wound healing. It may indicate systemic symptoms such as fever or chills, which could be indicative of infection or other complications.
B) Purulent drainage:
Purulent drainage (pus) is often a sign of infection rather than a normal inflammatory response to wound healing. While some serous or serosanguinous drainage may be expected initially, purulent drainage suggests an abnormal response.
C) Temperature of 102° F (37.8° C):
A temperature of 102° F (37.8° C) is indicative of fever, which can occur in response to infection or inflammation. While fever is part of the inflammatory response, it is not necessarily considered a normal finding in the context of wound healing and may indicate an abnormal response such as infection.
D) Redness and localized heat:
Correct. Redness (erythema) and localized heat are typical signs of the inflammatory phase of wound healing. Inflammation is a normal response to tissue injury and is characterized by increased blood flow to the area, resulting in redness and warmth. These signs indicate that the body's immune response is active and working to repair the injured tissue.
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