which of the following interventions is necessary before insertion of an arterial line into the radial artery

NCLEX-RN

Health Promotion and Maintenance NCLEX RN Questions

1. Which of the following interventions is necessary before insertion of an arterial line into the radial artery?

A. Ensure that the client does not need surgery
B. Assess the client's grip strength
C. Perform an Allen test
D. Check a serum potassium level

Correct answer: C

Rationale: Before inserting an arterial line into the radial artery, it is crucial to perform an Allen test. The Allen test assesses the collateral circulation to the hand by compressing both the radial and ulnar arteries. By occluding the radial artery and releasing the ulnar artery, the nurse can check if the ulnar artery can adequately supply blood to the hand if the radial artery is cannulated. This step ensures that there is adequate circulation to the hand post-insertion of the arterial line. Choice A, ensuring that the client does not need surgery, is not directly related to the insertion of an arterial line and is not a necessary step before the procedure. Choice B, assessing grip strength, is not specific to the vascular status of the hand and does not provide information about the adequacy of collateral circulation. Choice D, checking a serum potassium level, is unrelated to the assessment of radial artery patency and collateral circulation, which are the primary concerns before arterial line insertion.

2. The nurse is assessing a 3-year-old child for symptoms of autism spectrum disorder (ASD). Which assessment finding should lead the nurse to question the diagnosis?

A. Inability to react appropriately to social cues
B. Engages in repetitive behaviors
C. Comprehends language well beyond the complexity expected for age
D. Displays self-destructive behavior

Correct answer: C

Rationale: The correct answer is 'Comprehends language well beyond the complexity expected for age.' Children with autism spectrum disorder typically struggle with language and communication skills, so comprehending language well beyond their age level would not align with the diagnosis of ASD. This finding could indicate other developmental strengths or delays. Choices A, B, and D are more commonly associated with ASD - the inability to react appropriately to social cues, engaging in repetitive behaviors, and displaying self-destructive behavior are typical manifestations of autism spectrum disorder.

3. Which of the following statements best describes compartment syndrome?

A. An injury causes pain and tingling that starts in the buttock and travels down the leg.
B. An injury causes swelling within muscle tissue that leads to anoxia of nerves and muscles.
C. An injury causes permanent flexion of the interphalangeal joint, resulting in deformity.
D. An injury causes pain and swelling of the median plantar nerve.

Correct answer: B

Rationale: Compartment syndrome is characterized by swelling and increased pressure within a muscle compartment, leading to decreased blood flow and oxygen supply to nerves and muscles. This can result from various causes, such as trauma or the application of a cast after a fracture. If left untreated, compartment syndrome can lead to tissue necrosis. Choice A is incorrect as pain and tingling starting in the buttock and traveling down the leg are not specific features of compartment syndrome. Choice C is incorrect as permanent flexion of the interphalangeal joint is unrelated to compartment syndrome. Choice D is incorrect as pain and swelling of the median plantar nerve do not describe compartment syndrome.

4. A client with schizophrenia seems to stop focusing during a conversation with a nurse and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take?

A. Stop the interview at this point and resume later when the client is better able to concentrate
B. Ask the client, 'Are you seeing something on the ceiling?'
C. Tell the client, 'You seem to be looking at something on the ceiling. I see something there, too.'
D. Continue the interview without commenting on the client's behavior

Correct answer: B

Rationale: When a client with schizophrenia experiences a break in reality like staring at the ceiling and talking to themselves, the nurse should ask directly about the hallucination, as stated in choice B. By doing so, the nurse can assess the situation, identify the client's needs, and evaluate any potential risk for injury. Choices A, C, and D are incorrect. Stopping the interview (choice A) may not address the immediate concern of the hallucination. Providing false reassurance (choice C) or ignoring the behavior (choice D) does not actively address the client's altered perception of reality.

5. Which of the following conditions may warrant a serum creatinine level?

A. Rhabdomyolysis
B. Digitalis toxicity
C. Glomerulonephritis
D. All answers are correct

Correct answer: D

Rationale: A serum creatinine level may be warranted in conditions that can affect renal function or cause muscle breakdown. Rhabdomyolysis, characterized by muscle injury and breakdown, can lead to elevated creatinine levels due to the release of creatinine from muscles. Digitalis toxicity can impair renal function, leading to a need for monitoring creatinine levels. Glomerulonephritis, an inflammatory condition affecting the kidney's filtering units, can also impact renal function and require assessment of creatinine levels. Therefore, all the provided conditions may warrant a serum creatinine level to assess renal function and muscle breakdown.