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

Answer and Explanation

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.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Chronic hypertension is a significant risk factor for the development of various cardiac diseases, including coronary artery disease, left ventricular hypertrophy, heart failure, and arrhythmias. The increased workload on the heart caused by hypertension can lead to myocardial remodeling, impaired cardiac function, and ultimately heart disease.

B. Chronic hypertension can cause damage to the kidneys over time, leading to renal insufficiency or chronic kidney disease. The elevated blood pressure damages the delicate blood vessels in the kidneys, impairing their ability to filter waste products and regulate fluid and electrolyte balance. Persistent hypertension can ultimately lead to kidney dysfunction and renal failure.

C. Hypertension is a major risk factor for the development of stroke, particularly ischemic stroke (caused by a blockage in a blood vessel supplying the brain) and hemorrhagic stroke (caused by bleeding into the brain). Chronic hypertension can damage blood vessels in the brain, leading to the formation of blood clots or weakening of vessel walls, increasing the risk of stroke.

E. Chronic hypertension is a significant risk factor for the development of atrial fibrillation, a type of irregular heart rhythm characterized by rapid and chaotic electrical activity in the upper chambers of the heart (atria). The structural changes in the heart caused by hypertension, such as left atrial enlargement and fibrosis, can predispose individuals to atrial fibrillation.

D. Familial hypercholesterolemia is a genetic disorder characterized by high levels of LDL cholesterol in the blood. While chronic hypertension itself does not directly cause familial hypercholesterolemia, hypertension and hypercholesterolemia are often comorbid conditions that contribute to cardiovascular risk. Both conditions can lead to atherosclerosis, increasing the risk of heart disease and stroke.

F. Isolated systolic hypertension refers to elevated systolic blood pressure with normal diastolic blood pressure. While isolated systolic hypertension itself is a manifestation of hypertension, it is not a direct result of end-organ damage. However, if left untreated, isolated systolic hypertension can lead to complications such as stroke, heart failure, and kidney disease, which are consequences of end-organ damage from chronic hypertension.

A. The patient's blood pressure is 164/98. B. The patient appears somnolent. C. The patient's oxygen saturation is 90%. D. The patient reports feeling weak.

Correct Answer is B

Explanation

B Somnolence, or excessive sleepiness, can indicate respiratory depression, hypercapnia (elevated PaCO2), or impending respiratory failure. Somnolence in this context is concerning as it may suggest worsening respiratory status and impending respiratory compromise. Therefore, it should be immediately reported to the healthcare provider for further evaluation and intervention.

A blood pressure of 164/98 mmHg is elevated but may not necessarily require immediate intervention, especially if the patient is not exhibiting signs of acute hypertensive crisis or end-organ damage.

However, it should be closely monitored and managed as appropriate. While hypertension may contribute to respiratory distress, it may not be the most critical finding to report immediately in a patient with possible respiratory failure and a high PaCO2.

C An oxygen saturation of 90% indicates hypoxemia, which can exacerbate respiratory failure and contribute to respiratory distress. While hypoxemia requires prompt intervention to improve oxygenation, it may not be the most critical finding to report immediately if the patient is not showing signs of severe respiratory distress or impending respiratory failure. However, it should be closely monitored and managed to prevent further deterioration.

D Weakness is a nonspecific symptom and may be related to various underlying causes, including respiratory failure, electrolyte imbalances, or systemic illness. While weakness warrants further assessment and management, it may not be the most urgent finding to report immediately in a patient with possible respiratory failure and a high PaCO2 unless it is accompanied by other concerning symptoms or signs of impending respiratory compromise.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which is(are) potential result(s) of end-organ damage from chronic hypertension? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

When admitting a patient with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the health care provider?

Correct Answer is B

Explanation

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