While assessing a radial artery catheter, the client complains of numbness and pain distal to the insertion

site. What interventions should the nurse implement? -answer- Promptly remove the arterial catheter

from the radial artery.

A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To

differentiate the vascularsource of the intracranial bleeding, which finding should the nurse monitor?

-answer- Rapid onset of decreased level of consciousness.

When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to

treat bladder cancer, which instruction is most important for the nurse to include in the client's discharge

teaching plan? -answer- Report any signs of cloudy urine output.

After repositioning an immobile client, the nurse observes an area of hyperemia. To assess for blanching,

what action should the nurse take? -answer- Apply light pressure over the area.

The nurse enters a client's room and observes the client's wrist restraint secured as seen in the picture.

What action should the nurse take? -answer- Reposition the restraint tie onto the bedframe.

A female client with acute respiratory distresssyndrome (ARDS) is chemically paralyzed and sedated

while she is on as assist-control ventilator using 50% FIO2. Which assessment finding warrants

immediate intervention by the nurse? -answer- Diminished lef t lower lobe sounds

Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax, which required

immediate chest tube insertion to re-inflate the lung.

The development of atherosclerosis is a process of sequential events. Arrange the pathophysiological

events in orders of occurrence. (Place the first event on top and the last on the bottom) -answer- Arterial

endothelium injury causes inflammation

Macrophages consume low density lipoprotein (LDL), creating foam cells

Foam cellsrelease growth factors for smooth muscle cells