Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take immediate action?

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Question 1 of 5

Which assessment finding obtained by the nurse when caring for a patient with a right radial arterial line indicates a need for the nurse to take immediate action?

Correct Answer: A

Rationale: Choice A as a cooler hand suggests impaired blood flow, possibly from arterial occlusion, requiring immediate action. Normal MAP (choice B) and flush rates (choice C) don't warrant urgency, and tubing changes (choice D) follow a 96-hour protocol. This reflects NCLEX physiological integrity, prioritizing circulation assessment to prevent tissue damage in critical care.

Question 2 of 5

The nurse is caring for a patient with a subarachnoid hemorrhage who is intubated and placed on a mechanical ventilator with 10 cm Hâ‚‚O of peak end-expiratory pressure (PEEP). When monitoring the patient, the nurse will need to notify the health care provider immediately if the patient develops

Correct Answer: D

Rationale: Choice D as jugular distention suggests elevated intracranial pressure from PEEP, critical in subarachnoid hemorrhage. Normal saturation (choice A), respirations (choice B), and drainage (choice C) don't require immediate action. This reflects NCLEX physiological integrity, prioritizing neurological monitoring in critical care.

Question 3 of 5

A patient has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should

Correct Answer: B

Rationale: Choice B as using palms prevents indentations that could cause skin pressure during drying. Dependent positioning (choice A) increases swelling, gauze (choice C) distorts edges, and covering (choice D) traps heat. This aligns with NCLEX Physiological Integrity, ensuring proper cast care to avoid complications.

Question 4 of 5

The nurse is caring for a patient who is to be discharged from the hospital 5 days after insertion of a femoral head prosthesis using a posterior approach. Which statement by the patient indicates a need for additional instruction?

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 5 of 5

A pedestrian who was hit by a car is admitted to the emergency department with possible right lower leg fractures. The initial action by the nurse should be to

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

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