A client who is 2 hours post aortic valve replacement is in the intensive care unit (ICU). The low pressure alarm for the client's radial arterial line sounds. Which action should the nurse take first?

Question

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The low pressure alarm could signal hypotension. The nurse's first action should be to check the client for evidence of hypotension and the cause. Arterial lines carry the risk of hemorrhage and are most likely to occur at connection sites of the tubing and catheter. A client can lose a large amount of arterial blood in a short period of time. The nurse should verify that these connections are tight on admission of the client to the ICU. (Option B) A fast flush of the arterial line system (square wave test) should be performed after the nurse has ruled out a physiological cause of the low pressure alarm. This test helps to verify if the arterial line is functioning correctly. (Option C) The transducer should be leveled to the client's phlebostatic axis to measure arterial pressure correctly. However, this should be done after the client has been checked for a physiological cause of the alarm. (Option D) Zeroing the monitor should be done if measurement accuracy is questioned. However, this should be done after the client has been taken care of. Educational objective: A low pressure alarm for an arterial line can indicate the presence of hypotension or disconnected tubing. Hemorrhage can rapidly occur with a disconnected arterial catheter line. The nurse should check the client for the presence of hypotension and its causes before troubleshooting the system.

A Client Who Is 2 Hours Post Aortic Valve Replacement