The nurse is concerned that the hand with an arterial line in the wrist is becoming ischemic. What did the nurse assess in this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. Delayed capillary refill
2. Pale skin color of the wrist and hand
3. Reduced pulses in the brachial artery
4. Hand cold to touch
5. Blood pressure discrepancy of 15 mm Hg
1,2,4
Rationale 1: Evidence of tissue ischemia in the cannulated extremity includes delayed capillary refill.
Rationale 2: Evidence of tissue ischemia in the cannulated extremity includes pallor.
Rationale 3: Evidence of tissue ischemia in the cannulated extremity includes a reduction in pulses distal to the cannula.
Rationale 4: Evidence of tissue ischemia in the cannulated extremity includes cool temperature.
Rationale 5: This is not evidence of tissue ischemia in the cannulated extremity.
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