A nurse is taking ABG sample through the radial artery. During the procedure, a vein is pricked instead of an artery. What would be the expected and first response of the nursing officer?

1. A

   Hematoma formation and compress the site

2. B

   Blood clot but send the lab

3. C

   Take the sample from another hand

4. D

   Maintain the records

Appeared in: NORCET 5 mains

Explanation

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• When a blood vessel is punctured, blood can leak into the surrounding tissue, forming a hematoma (bruise). This is the most expected immediate complication.
• The priority nursing action is to stop the bleeding and limit the size of the hematoma.
• Applying firm, direct pressure to the puncture site for at least 5 minutes is the standard procedure to achieve hemostasis (stop bleeding).
• This action prevents further blood leakage, reduces pain and swelling, and minimizes the risk of compressing nearby nerves.

Why Other Options Were Wrong

• Option B: Sending a venous sample for ABG analysis is clinically inappropriate. ABG tests require arterial blood to accurately measure gas exchange and acid-base status. A venous sample would provide misleading results.
• Option C: This is not the immediate or first action. The priority is to manage the complication at the current puncture site before attempting the procedure again.
• Option D: Documentation is an essential nursing responsibility, but it is not the first priority in an acute situation. Immediate patient safety and physiological stability always come before paperwork.

Related Visual

• Visual 1: Diagram - Showing the formation of a hematoma after a needle puncture, illustrating blood leaking from a vessel into subcutaneous tissue.
• Visual 2: Infographic - Step-by-step guide on how to correctly apply pressure to a puncture site to control bleeding.

Clinical Relevance

• Nursing practice connection: Knowing Complications and immediate nursing management of arterial blood gas (ABG) sampling helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
• Patient Safety: Immediate application of pressure after an incorrect vessel puncture is a critical patient safety measure to prevent complications like large hematomas, which can cause significant pain and potentially compress nerves or compromise circulation.
• Specimen Integrity: Nurses must ensure the correct type of sample is collected for the ordered test. Sending a venous sample for an ABG analysis can lead to incorrect diagnosis and treatment.
• What if?: If the patient was on anticoagulant therapy (e.g., warfarin or heparin), the nurse would need to apply pressure for a longer duration (e.g., 10-15 minutes or more) and monitor the site more closely due to the increased risk of bleeding.

How to Approach the Question

• First, identify the core of the question: it asks for the expected complication and the first nursing response to a specific procedural error (puncturing a vein during an ABG draw).
• Analyze the error: Puncturing a blood vessel carries the risk of bleeding. The immediate goal is to stop the bleeding.
• Evaluate the options based on nursing priorities (think: ABCs, safety). The most immediate need is to control the bleeding at the site.
• Option A addresses both the complication (hematoma) and the immediate action (compression).
• Eliminate other options: Sending the wrong sample is a procedural error. Trying again or documenting are subsequent actions, not the first response to the complication.

Concept Tested & Keywords

• Concept Tested: Complications and immediate nursing management of arterial blood gas (ABG) sampling.
• Stem keywords: ABG sample, radial artery, vein pricked, first response
• Lead-in keywords: expected and first response
• Clinical cues: Procedure: ABG sampling
• Clinical cues: Error: Vein punctured instead of artery

Question ID

QYBvVtB3QKBzXa31dERIw8

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