The nurse assesses a client postoperatively who has an arterial line in the right radial artery. Assessment findings include pallor, paresthesia, and slow capillary refill in the client's right-hand fingers. Which action should the nurse take?

Perform the Allen test.

Elevate the client's right arm.

Flush the line with heparinized saline.

Notify the healthcare provider.

Answer and Explanation

The Correct Answer is D

A. Perform the Allen test. The Allen test is performed before inserting a radial arterial line to assess ulnar artery patency and ensure adequate collateral circulation. Since the arterial line is already placed and the client is showing signs of compromised circulation (pallor, paresthesia, and slow capillary refill), immediate intervention is required rather than further pre-insertion testing.
B. Elevate the client's right arm. Elevating the arm does not directly resolve arterial compromise and may further reduce perfusion by impairing arterial blood flow. The priority is to assess and address potential ischemia caused by arterial line complications.
C. Flush the line with heparinized saline. Flushing an arterial line is appropriate for maintaining patency, but in this case, it may worsen ischemia if the catheter is causing an obstruction or arterial spasm. Additionally, flushing should never be done forcefully due to the risk of embolization.
D. Notify the healthcare provider. The pallor, paresthesia, and delayed capillary refill suggest arterial insufficiency, possible thrombosis, or arterial spasm, which can lead to tissue ischemia and necrosis if not addressed promptly. The healthcare provider should be notified immediately to assess the need for interventions such as removal of the arterial line, vascular assessment, or anticoagulation therapy.

Nursing Test Bank

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Correct Answer is D

Explanation

A. Measure the client's abdominal girth. While tracking abdominal distension is useful, it does not address the underlying cause of the client's deterioration. Measuring girth should not delay immediate intervention for a potentially life-threatening condition.
B. Monitor the client's recent hemoglobin levels. A drop in hemoglobin would indicate internal bleeding, but waiting for lab results could delay necessary treatment. The client is already showing signs of early shock, requiring urgent medical intervention rather than just monitoring.
C. Prepare for nasogastric tube (NGT) insertion. An NGT may be needed for bowel obstruction or paralytic ileus, but the client's worsening condition suggests a more urgent issue, such as intra-abdominal hemorrhage. Addressing the potential bleeding takes priority over decompression.
D. Notify the healthcare provider (HCP) of the client's status. The client's tachycardia, tachypnea, cool pale skin, and worsening abdominal distension suggest early shock, likely due to postoperative internal bleeding or abdominal compartment syndrome. Immediate notification of the HCP ensures rapid assessment, diagnostic testing, and potential emergency intervention to prevent further deterioration.

A. Suction subglottic area above the ETT cuff before entering the ETT. B. Use the ventilator settings to stack breaths prior to suctioning. C. Rinse suction catheters with normal saline between each suction pass. D. Suction for 30 seconds with each pass of the suction catheter.

Correct Answer is B

Explanation

A. Suction subglottic area above the ETT cuff before entering the ETT. While subglottic suctioning helps prevent ventilator-associated pneumonia (VAP) by removing pooled secretions, it does not directly improve oxygenation during deep endotracheal suctioning. The priority is to optimize oxygenation before and after suctioning.
B. Use the ventilator settings to stack breaths prior to suctioning. Pre-oxygenating the client by delivering additional breaths via the ventilator helps prevent hypoxia during suctioning. Closed suction systems momentarily interrupt airflow, which can lead to oxygen desaturation. Providing 100% FiO₂ for 30–60 seconds before suctioning helps ensure adequate oxygenation and reduces complications.
C. Rinse suction catheters with normal saline between each suction pass. Flushing the catheter keeps it clean and patent, but it does not enhance oxygenation. Normal saline instillation before suctioning is not recommended, as it can increase infection risk and worsen secretion mobilization.
D. Suction for 30 seconds with each pass of the suction catheter. Prolonged suctioning can cause severe hypoxia, bradycardia, and airway trauma. Suction passes should be limited to 10–15 seconds to minimize complications. If additional suctioning is needed, the client should be reoxygenated between passes.

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The nurse assesses a client postoperatively who has an arterial line in the right radial artery. Assessment findings include pallor, paresthesia, and slow capillary refill in the client's right-hand fingers. Which action should the nurse take?

Nursing Test Bank

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Explanation

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Explanation

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