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

distal to the insertion site. What interventions should the nurse implement? -

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 vascular source of the intracranial bleeding, which

finding should the nurse monitor? - 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? - 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? - 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? - Reposition the restraint tie

onto the bedframe.

A female client with acute respiratory distress syndrome (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? -

Diminished left lower lobe sounds

Rationale: Diminished lobe sounds indicate collapsed alveoli or tension

pneumothorax, which required immediate chest tube insertion to re-inflate the

lung.