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 D

Explanation

D. A drop in oxygen saturation may indicate inadequate oxygenation, which could be due to airway obstruction or retained secretions.

A. While audible expiratory wheezes may indicate airway obstruction or secretions, they do not necessarily indicate the need for suctioning in a patient receiving mechanical ventilation.

B. An elevated respiratory rate may suggest increased work of breathing, which could be due to retained secretions or airway obstruction. However, an elevated respiratory rate alone may not always indicate the need for suctioning.

C. The timing of the last suctioning episode is an important consideration when determining the need for suctioning. However, it should not be the sole indicator for when to suction.

A. Remove clothing for a thorough assessment. B. Determine effectiveness of ventilator efforts. C. Open the airway using a jaw-thrust maneuver. D. Establish IV access. E. Perform a Glasgow Coma Scale assessment.

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

Explanation

First, the nurse should open the airway using a jaw-thrust maneuver (C) to ensure it is not obstructed. Next, they should determine the effectiveness of ventilatory efforts (B), as breathing is critical and any compromise must be addressed immediately. Following this, establishing IV access (D) is important for fluid resuscitation and medication administration. The nurse should then perform a Glasgow Coma Scale assessment (E) to determine the level of consciousness and neurological function. Lastly, removing clothing for a thorough assessment (A) is essential, but only after the critical steps concerning airway, breathing, circulation, and disability have been addressed.

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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?

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Naxlex Comprehensive Predictor Exams

Which assessment finding by the nurse caring for a patient receiving mechanical ventilation indicates the need for suctioning?

Correct Answer is D

Explanation

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

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

Explanation

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