When caring for a patient who has an arterial catheter in the ...

[anjilletteb]

When caring for a patient who has an arterial catheter in the left radial artery for arterial pressurebased cardiac output (APCO) monitoring, which information obtained by the nurse is most important to report to the health care provider?
 
  a. The patient has a positive Allen test.
  b. There is redness at the catheter insertion site.
  c. The mean arterial pressure (MAP) is 86 mm Hg.
  d. The dicrotic notch is visible in the arterial waveform.

Question 2

An 81-year-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. The nurse will plan to
 
  a. give PRN lorazepam (Ativan) and cancel the transfer.
  b. inform the receiving nurse and then transfer the patient.
  c. notify the health care provider and postpone the transfer.
  d. obtain an order for restraints as needed and transfer the patient.

[batool]

Answer to Question 1

ANS: B
Redness at the catheter insertion site indicates possible infection. The Allen test is performed before arterial line insertion, and a positive test indicates normal ulnar artery perfusion. A MAP of 86 is normal and the dicrotic notch is normally present on the arterial waveform.

Answer to Question 2

ANS: B
The patient's history and symptoms most likely indicate delirium associated with the sleep deprivation and sensory overload in the ICU environment. Informing the receiving nurse and transferring the patient is appropriate. Postponing the transfer is likely to prolong the delirium. Benzodiazepines and restraints contribute to delirium and agitation.