The nursing is caring for a patient who has had a left radial arterial line inserted 10 minutes ago. To reduce the risk of complications, what is the priority nursing intervention?
Ensure all tubing connections are tightened
Apply a pressure dressing to the insertion site
Perform an Allen's test
Obtain a portable x-ray to confirm placement
The Correct Answer is A
A. Ensure all tubing connections are tightened: Tight tubing connections are critical in preventing accidental disconnection, which can result in rapid blood loss and air embolism. Arterial lines are under high pressure, so securing all connections is a top priority to ensure patient safety and maintain line integrity.
B. Apply a pressure dressing to the insertion site: A transparent occlusive dressing not a pressure dressing is used for arterial lines to allow for site visualization and reduce the risk of infection. A pressure dressing could obscure signs of bleeding or compromise the catheter’s position.
C. Perform an Allen's test: Allen’s test is performed prior to radial arterial line insertion to assess collateral circulation via the ulnar artery for preventing ischemic complications if the radial artery is compromised. Performing the test afterward does not prevent complications and is no longer relevant once the catheter is placed.
D. Obtain a portable x-ray to confirm placement: X-rays are used to confirm the placement of central lines, not peripheral arterial lines like the radial line. Arterial line placement is confirmed by waveform analysis and blood return, not imaging.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Atria is taking longer to depolarize and contract: This would be indicated by a prolonged or abnormal P wave, not a normal PR interval. The rhythm strip shows clearly visible, normal-appearing P waves followed by QRS complexes, ruling this out as the correct interpretation.
B. Conduction time is slowed from the SA node to the ventricles: A slowed conduction time would result in a PR interval longer than 0.20 seconds, characteristic of first-degree AV block. The PR interval on this strip measures within the standard range (0.12–0.20 seconds), so this is not accurate.
C. The PR interval is within the normal time limits: The PR interval on the ECG strip spans about 3 to 4 small boxes (0.12–0.16 seconds), which is within the normal range of 0.12 to 0.20 seconds. This indicates normal conduction from the atria through the AV node to the ventricles.
D. Ventricular repolarization is delayed: Delayed ventricular repolarization refers to a prolonged QT interval, not an abnormality in the PR interval. The PR interval evaluates atrial conduction, not ventricular repolarization, so this is an incorrect association.
Correct Answer is E
Explanation
A. contact the prescriber to decrease the rate of the D51/2NS during the blood transfusion: There's no need to alter the rate of maintenance fluids unless there's a fluid volume concern. Additionally, decreasing the rate would not address the need for a dedicated blood transfusion line if another lumen is available.
B. stop the D51/2NS, check the client's vitals & notify the prescriber: Stopping necessary fluids without cause may compromise fluid balance. Unless there's a compatibility issue or no other lumen, stopping the infusion is not the safest or most efficient action.
C. Fluids cannot be given through a CVC: Central venous catheters are routinely used for administering fluids, medications, and blood products, especially in critical care settings.
D. Insert a 22 gauge peripheral IV to administer the transfusion: While blood can be given through a peripheral IV, using an existing central venous catheter is safer and more efficient, especially when multiple lumens are available. Inserting a new IV unnecessarily increases infection and complication risks.
E. transfuse the unit of packed red blood cells through a separate lumen of the CVC: This is the safest and most appropriate action. Triple-lumen CVCs allow for simultaneous infusions through separate channels without mixing. Blood should be transfused through a dedicated lumen to avoid incompatibility or dilution by other fluids.
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