When should the nurse conduct an Allen's test?
Just before arterial blood gasses are drawn peripherally.
Prior to attempting a cardiac output calculation.
To assess for presence of a deep vein thrombus in the leg.
When pulmonary artery pressures are obtained.
The Correct Answer is A
Allen's test is a procedure used to assess the patency of the ulnar artery and the collateral circulation of the hand. It is performed to determine the adequacy of collateral circulation before obtaining arterial blood gases from the radial artery. The test helps ensure that the ulnar artery is functioning properly and can supply blood to the hand if the radial artery is used for blood sampling or other invasive procedures.
The test involves occluding both the ulnar and radial arteries while the patient clenches their fist. The nurse then releases pressure on the ulnar artery while maintaining occlusion of the radial artery. The hand should quickly regain normal coloration, indicating adequate collateral circulation.
It's important to note that the Allen's test is specific to the assessment of collateral circulation in the hand and is not used for other purposes such as assessing deep vein thrombosis, cardiac output calculation, or obtaining pulmonary artery pressures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Incorrect - Encouraging the use of ice on the areola is not a recommended intervention for addressing inverted nipples and promoting successful breastfeeding.
B) Incorrect - Teaching about the use of a breast pump might be useful for milk expression but may not directly address the issue of latching due to inverted nipples.
C) Incorrect - Offering supplemental formula feedings does not address the underlying issue of inverted nipples and breastfeeding difficulties.
D) Correct-inverted nipples can make breastfeeding challenging as the baby may have difficulty latching directly onto the breast. A breast shield can be recommended to help draw out the nipple and create a more optimal shape for latching. It can also provide a larger surface area for the baby to grasp onto, making breastfeeding more successful for both the mother and the baby.
Correct Answer is B
Explanation
A) Incorrect- A blood pressure of 130/80 mm Hg is within a generally acceptable range for a person with diabetes and coronary artery disease. It may not directly indicate a complication related to the episodes of confusion. While blood pressure management is important for clients with diabetes and coronary artery disease, this particular blood pressure reading is not necessarily a significant finding in relation to the client's confusion.
B) Correct- Cervical spine stiffness or neck stiffness is a potential neurological symptom that can indicate a serious complication in a client with type 2 diabetes and coronary artery disease. The stiffness of the neck may be a sign of meningeal irritation, which can result from various conditions including infections such as meningitis. The client's medical history includes both type 2 diabetes and coronary artery disease, which are risk factors for cardiovascular events, including cerebrovascular accidents (strokes). Confusion can be a symptom of a stroke, and neck stiffness can be indicative of meningeal irritation secondary to a stroke or another neurological condition.
C) Incorrect- Dark yellow urine can be a sign of dehydration, which can be a concern for someone with diabetes. However, it is not directly related to episodes of confusion. Dehydration can cause various symptoms, but confusion is not typically associated with mild dehydration.
D) Incorrect- Excessive perspiration (diaphoresis) can occur for various reasons, including increased sympathetic nervous system activity, fever, anxiety, and physical activity. While it can be a symptom of certain complications, such as hypoglycemia (low blood sugar) or heart attack, it alone may not directly relate to the episodes of confusion in this client.
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