Question

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 action?

a. The right hand feels cooler than the left hand.
b. The mean arterial pressure (MAP) is 77 mm Hg.
c. The system is delivering 3 mL of flush solution per hour.
d. The flush bag and tubing were last changed 2 days previously.

Answer 1

The nurse needs to take action if the patient's right hand feels cooler than the left hand, as this suggests compromised blood flow due to the radial arterial line. A MAP of 77 mm Hg and a flush solution delivery of 3 mL per hour are both standard, and changing the flush bag and tubing every 2 days is generally acceptable.

Step-by-step explanation:

The assessment finding that indicates a need for the nurse to take action when caring for a patient with a right radial arterial line is that the right hand feels cooler than the left hand. This could signify compromised blood flow to the right hand, which may result from a blockage or malfunction in the arterial line. Immediate assessment and intervention are required to restore proper blood flow and prevent tissue damage. In contrast, a mean arterial pressure (MAP) of 77 mm Hg is within the normal range, and delivery of 3 mL of flush solution per hour is standard for maintaining patency of an arterial line. Although the flush bag and tubing should generally be changed every 96 hours as per CDC guidelines, changing them every 2 days exceeds this recommendation and does not immediately require action unless there are signs of infection or other specific protocols in place.