Author Question: A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse ... (Read 109 times)

future617RT · **on:** Jun 25, 2018

A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first?

a. Amount of pressure in fluid container
b. Date of catheter tubing change
c. Percent of heparin in infusion container
d. Presence of an ulnar pulse

Question 2

A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the client's skin during this procedure?

a. Lower the extremity below the level of the heart.
b. Apply warm compresses to the extremity.
c. Tap the skin lightly and avoid slapping.
d. Place a washcloth between the skin and tourniquet.

Tonny · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: D
An intra-arterial catheter may cause arterial occlusion, which can lead to absent or decreased perfusion to the extremity. Assessment of an ulnar pulse is one way to assess circulation to the arm in which the catheter is located. The nurse would note that there is enough pressure in the fluid container to keep the system flushed, and would check to see whether the catheter tubing needs to be changed. However, these are not assessments of greatest concern. Because of heparin-induced thrombocytopenia, heparin is not used in most institutions for an arterial catheter.

Answer to Question 2

ANS: D
To protect the client's skin, the nurse should place a washcloth or the client's gown between the skin and tourniquet. The other interventions are methods to distend the vein but will not protect the client's skin.