The nurse performs an Allen's test on a client scheduled for an arterial blood gas
draw from the radial artery. On release of pressure from the ulnar artery, color in the
hand returns after 20 seconds. How should the nurse interpret the finding? Fill in the
correct missing information by choosing from the lists of options in the drop-down
menus.
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, The test result is
Your Answer: Abnormal Correct Answer: Abnormal
because
Your Answer: The time for color to return is prolonge Correct Answer: The
time for color to return is prolonged
Rationale:Failure to determine the presence of adequate collateral
circulation before drawing an arterial blood gas specimen could result in
severe ischemic injury to the hand if damage to the radial artery occurs with
arterial puncture. Upon release of pressure on the ulnar artery, if pinkness
fails to return within 6 to 7 seconds, the ulnar artery is insufficient, indicating
that the radial artery should not be used for obtaining a blood specimen.
Another site needs to be selected for the arterial puncture, and the primary
health care provider needs to be notified of the finding.
The nurse caring for a child with a diagnosis of leukemia receives a report from the
laboratory indicating that the white blood cell count is 2000/mm3 (2.0 × 109/L) and the
absolute neutrophil count (ANC) is 40% (0.40). Vital signs are unchanged from
baseline and the child denies pain. The nurse determines that further actions are
needed to care for this client based on this information. Fill in the correct missing
information by selecting from the lists of options in the drop-down menus.
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ActionSupporting findingRationale
Your Answer:1. Private roomCorrect Answer:1. Private room
ANC less than 50% (0.50)Severe infection risk is presentAlcohol-based
hand rub or hand washing
Your Answer:2. ANC less than 50% (0.50)Correct Answer:2. ANC less than
50% (0.50)
Severe infection risk is presentKeep fresh flowers out of the roomANC less
than 50% (0.50)
Your Answer:1. Can harbor bacteriaCorrect Answer:1. Can harbor bacteria
121
Rationale:A white blood cell count of 2000/mm3 (2.0 × 109/L) and an
absolute neutrophil count of 40% (0.40) are indicative of a neutropenic
, state, and the child should be placed on neutropenic precautions. The
absolute neutrophil count (ANC) is the standard of care in determining
whether a child is in a neutropenic state and the need for protective
isolation and other hygienic measures. If the ANC is less than 50% (0.50), a
severe infection risk is present. Interventions include a private room; good
hand-washing technique or use of an alcohol-based hand rub before
entering the child's room and before touching the client or any belongings;
ensuring that the child's room and bathroom are cleaned a minimum of
once per day; limiting the number of people entering the child's room (no
sick persons should enter the room); using strict aseptic technique for all
invasive procedures; keeping fresh flowers and potted plants out of the
room; and implementing a low-bacteria diet (no fresh fruits or vegetables
or undercooked meats).
The nurse is assessing an infant with clubfoot who is in a cast. The nurse notes the
following clinical findings on assessment.Vital signs:
Blood pressure 90/60 mm Hg
Heart rate 112 beats per minute
Respirations 24 breaths per minute
Oxygen saturation 98% on room air
Temperature 36.4° C (97.5° F)
Musculoskeletal findings : Tissue distal to the cast is pale and edematous.The infant
shows signs of pain with passive movement.
Which actions should the nurse take? Select all that apply.
Give this one a try later!
draw from the radial artery. On release of pressure from the ulnar artery, color in the
hand returns after 20 seconds. How should the nurse interpret the finding? Fill in the
correct missing information by choosing from the lists of options in the drop-down
menus.
Give this one a try later!
, The test result is
Your Answer: Abnormal Correct Answer: Abnormal
because
Your Answer: The time for color to return is prolonge Correct Answer: The
time for color to return is prolonged
Rationale:Failure to determine the presence of adequate collateral
circulation before drawing an arterial blood gas specimen could result in
severe ischemic injury to the hand if damage to the radial artery occurs with
arterial puncture. Upon release of pressure on the ulnar artery, if pinkness
fails to return within 6 to 7 seconds, the ulnar artery is insufficient, indicating
that the radial artery should not be used for obtaining a blood specimen.
Another site needs to be selected for the arterial puncture, and the primary
health care provider needs to be notified of the finding.
The nurse caring for a child with a diagnosis of leukemia receives a report from the
laboratory indicating that the white blood cell count is 2000/mm3 (2.0 × 109/L) and the
absolute neutrophil count (ANC) is 40% (0.40). Vital signs are unchanged from
baseline and the child denies pain. The nurse determines that further actions are
needed to care for this client based on this information. Fill in the correct missing
information by selecting from the lists of options in the drop-down menus.
Give this one a try later!
ActionSupporting findingRationale
Your Answer:1. Private roomCorrect Answer:1. Private room
ANC less than 50% (0.50)Severe infection risk is presentAlcohol-based
hand rub or hand washing
Your Answer:2. ANC less than 50% (0.50)Correct Answer:2. ANC less than
50% (0.50)
Severe infection risk is presentKeep fresh flowers out of the roomANC less
than 50% (0.50)
Your Answer:1. Can harbor bacteriaCorrect Answer:1. Can harbor bacteria
121
Rationale:A white blood cell count of 2000/mm3 (2.0 × 109/L) and an
absolute neutrophil count of 40% (0.40) are indicative of a neutropenic
, state, and the child should be placed on neutropenic precautions. The
absolute neutrophil count (ANC) is the standard of care in determining
whether a child is in a neutropenic state and the need for protective
isolation and other hygienic measures. If the ANC is less than 50% (0.50), a
severe infection risk is present. Interventions include a private room; good
hand-washing technique or use of an alcohol-based hand rub before
entering the child's room and before touching the client or any belongings;
ensuring that the child's room and bathroom are cleaned a minimum of
once per day; limiting the number of people entering the child's room (no
sick persons should enter the room); using strict aseptic technique for all
invasive procedures; keeping fresh flowers and potted plants out of the
room; and implementing a low-bacteria diet (no fresh fruits or vegetables
or undercooked meats).
The nurse is assessing an infant with clubfoot who is in a cast. The nurse notes the
following clinical findings on assessment.Vital signs:
Blood pressure 90/60 mm Hg
Heart rate 112 beats per minute
Respirations 24 breaths per minute
Oxygen saturation 98% on room air
Temperature 36.4° C (97.5° F)
Musculoskeletal findings : Tissue distal to the cast is pale and edematous.The infant
shows signs of pain with passive movement.
Which actions should the nurse take? Select all that apply.
Give this one a try later!
