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 C

Explanation

C. The first intervention should be to administer normal saline IV at 500 mL/hr to address the immediate concern of hypotension and inadequate tissue perfusion.

A. While fever control is important, especially in septic shock, administering acetaminophen should not be the first intervention in a patient with severe hypotension and shock. Addressing the low blood pressure and perfusion is a higher priority.

B. Hyperglycemia is common in critically ill patients, including those with septic shock. However, in this scenario, the patient's severely low blood pressure and signs of shock take precedence over managing hyperglycemia. Insulin therapy can be initiated later once the patient's hemodynamic status is stabilized.

D. Norepinephrine is a vasopressor medication commonly used in septic shock to increase blood pressure and improve perfusion to vital organs. It helps counteract the vasodilation and hypotension characteristic of septic shock.

A. The patient has no cough reflex when suctioned. B. The patient's oxygen saturation is 90% to 93% C. The patient does not respond to voice. D. No sedative is ordered for the patient

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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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

A patient with septic shock has a BP of 70/46 mm Hg. pulse of 136 beats/min, respirations of 32 breaths/min, temperature of 104" F, and blood glucose of 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

Correct Answer is C

Explanation

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?

Correct Answer is D

Explanation

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