An arterial catheter is inserted in the right radial artery to monitor a patient's blood pressure. Which information obtained by the nurse indicates that a complication of arterial pressure monitoring may be occurring?
Allen's test is positive.
The mean arterial pressure (MAP) is 90 mm Hg.
The dicrotic notch is visible in the waveform.
The right hand is numb.
The Correct Answer is D
Arterial pressure monitoring involves the insertion of an arterial catheter, typically in the radial artery, to directly measure blood pressure. Complications can arise from this invasive procedure, and one potential complication is inadequate blood flow to the hand, leading to numbness or ischemia.
A. The Allen's test is positive in (option A) is incorrect because The Allen's test is performed before arterial catheter insertion to assess the collateral circulation of the hand. A positive Allen test indicates adequate collateral circulation, which is desirable before performing the procedure. However, it does not directly indicate a complication during or after arterial pressure monitoring.
B. The mean arterial pressure (MAP) is 90 mm Hg in (option B) is incorrect because The mean arterial pressure (MAP) represents the average pressure in the arterial system during one cardiac cycle. While changes in MAP can be significant for patient management, it does not specifically indicate a complication of arterial pressure monitoring.
C. The dicrotic notch visible in the waveform in (option C) is incorrect because The dicrotic notch represents the closure of the aortic valve and is a normal finding in arterial waveforms. Its presence does not indicate a complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
In a patient receiving mechanical ventilation, a high respiratory rate can indicate increased work of breathing and potential airway obstruction. COPD patients, in particular, may have excessive mucus production and airway inflammation, leading to mucus plugging and compromised airway clearance. Suctioning may be necessary to remove excessive secretions and maintain a patent airway.
A. The pulse oximeter shows a SpO2 of 90% in (option A) is incorrect because While a SpO2 of 90% is suboptimal and may require intervention, it does not specifically indicate the need for suctioning. Other interventions, such as adjusting oxygen delivery or ventilation settings, may be more appropriate.
B. The patient has not been suctioned for the last 6 hours in (option B) is incorrect because The duration since the last suctioning episode alone does not necessarily indicate the need for suctioning. The need for suctioning should be based on the patient's clinical presentation, such as signs of airway obstruction or excessive secretions.
D. The lungs have occasional audible expiratory wheezes in (option D) which is incorrect because Occasional audible expiratory wheezes may be common in patients with COPD and may not specifically indicate the need for suctioning. Wheezing is more commonly associated with narrowing of the airways, and suctioning is typically performed to clear secretions or maintain airway patency.
C. Therefore, in a COPD patient receiving mechanical ventilation, a high respiratory rate (C) is the assessment information that would indicate the need for suctioning to help remove excessive secretions and ensure a patent airway
Correct Answer is A
Explanation
Tachypnoea, which refers to an increased respiratory rate, is an early symptom of hypovolemic shock. It is the body's compensatory response to inadequate tissue perfusion and decreased oxygen delivery. The increased respiratory rate is an attempt to improve oxygenation and maintain vital organ function.
B. Heart blocks in (option B) are incorrect because Heart blocks refer to disruptions in the electrical conduction system of the heart and are not specific to hypovolemic shock.
C. Vomiting in (option C) is incorrect because: Vomiting may occur in various conditions, including shock, but it is not exclusive to hypovolemic shock and can be present in other forms of shock or illnesses.
D. Bradycardia in (option D) is incorrect because Bradycardia, or a slow heart rate, is not typically an early symptom of hypovolemic shock. Instead, tachycardia (rapid heart rate) is more commonly observed as a compensatory response to maintain cardiac output.
E. Hypotension in (option E) is incorrect because Hypotension, or low blood pressure, can occur in hypovolemic shock but is generally considered a later-stage symptom. In the early stages, compensatory mechanisms may help maintain blood pressure, so hypotension may not be present initially.
F. Bradypnea in (option F) is incorrect because: Bradypnea refers to a slow respiratory rate, which is not typically an early symptom of hypovolemic shock. Tachypnoea, as mentioned earlier, is the more common early respiratory symptom.
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