NCLEX RN Practice Question # 575

NCLEX Examination.

Practice Question # 575.


 

Nclex

 

ARTERIAL BLOOD GASES

Collection of an arterial blood gas specimen

  • Obtain vital signs.
  • Determine whether the client has an arterial line in place.
  • Perform the Allen’s test to determine the presence of collateral circulation.
  • Assess factors that may affect the accuracy of the results, such as changes in theO2 settings, suctioning within the past 20minutes, and client’s activities.
  • Provide emotional support to the client.
  • Assist with the specimen draw by preparing a heparinized syringe.
  • Apply pressure immediately to the puncture site following the blood draw; maintain pressure for 5 minutes, or for 10 minutes if the client is taking anticoagulants.
  • Appropriately label the specimen and transport it on ice to the laboratory.
  • On the laboratory form, record the client’s temperature and the type of supplemental oxygen that the client is receiving.

Normal values of Arterial blood gasses

Priority Nursing Actions!

Actions to Take When Performing the Allen’s Test

  • Explain the procedure to the client.
  • Apply pressure over the ulnar and radial arteries simultaneously.
  • Ask the client to open and close the hand repeatedly.
  • Release pressure from the ulnar artery while compressing the radial artery.
  • Assess the color of the extremity distal to the pressure point.
  • Document the findings.

The Allen’s test is performed before obtaining an arterial blood specimen from the radial artery to determine the presence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. The nurse first would explain the procedure to the client. To perform the test, the nurse applies direct pressure over the client’s ulnar and radial arteries simultaneously. While applying pressure, the nurse asks the client to open and close the hand repeatedly; the hand should blanch.

Leave a Reply

Follow Us

Follow us on Facebook