Which action should the nurse take first when the low pressure alarm sounds for a patient who has an arterial line in the left radial artery?
Re-zero the monitoring equipment.
Check the left hand for pallor.
Fast flush the arterial line.
Assess for dysrhythmias
The Correct Answer is B
B. Checking the left hand for pallor can help assess peripheral perfusion and determine if there is adequate blood flow distal to the arterial line insertion site. Pallor in the left hand could indicate decreased perfusion, which may contribute to the low-pressure alarm.
A. Re-zeroing the monitoring equipment may be necessary to ensure accurate pressure readings. However, it should not be the first action taken when the low-pressure alarm sounds. Before re-zeroing, the nurse should assess the patient's condition to ensure there are no immediate issues affecting arterial pressure.
C. Fast flushing the arterial line is not typically the first action to take when the low-pressure alarm sounds. Fast flushing may increase the risk of dislodging the catheter or causing air embolism if there is a problem with the line.
D. Assessing for dysrhythmias should be part of the overall assessment but may not be the first action taken in response to the alarm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
In respiratory acidosis, there is an accumulation of carbon dioxide (CO2) in the blood due to inadequate ventilation, leading to an increase in the partial pressure of arterial carbon dioxide (PaCO2) and a decrease in pH.
This is often caused by conditions that impair ventilation, such as airway obstruction, respiratory muscle weakness, lung diseases (e.g., chronic obstructive pulmonary disease, pneumonia), or central nervous system depression (e.g., drug overdose, head injury).
Management of respiratory acidosis include bronchodilators, sodium bicarbonate, adequate ventilation, and treatment of underlying causes.
Correct Answer is D
Explanation
D Sedatives are typically administered alongside neuromuscular blockers to ensure the patient's comfort and prevent awareness during mechanical ventilation.
A The absence of a cough reflex when suctioned is expected in a patient receiving cisatracurium (Nimbex) because it is a neuromuscular blocking agent that induces paralysis. Cisatracurium inhibits skeletal muscle movement, including the muscles involved in coughing.
B An oxygen saturation between 90% to 93% is within an acceptable range for a patient in this condition.
C The lack of response to voice may indicate that the patient is sedated or experiencing effects from the neuromuscular blocking agent. However, since the patient is receiving cisatracurium to prevent asynchronous breathing with the positive pressure ventilator, it's expected that the patient will not respond to voice due to the medication-induced paralysis.
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