Which is the appropriate nursing action by nursing officer after taking ABG sample from radial artery?

Combined AIIMS - 2020 (Jodhpur, Bhopal, Patna, Raipur)

Nursing Foundation

Easy

Appeared in: Combined AIIMS - 2020 (Jodhpur, Bhopal, Patna, Raipur)

Explanation

The immediate priority after an ABG draw is to achieve hemostasis (stop bleeding) at the puncture site.
The radial artery is a high-pressure vessel, which carries a significant risk of hemorrhage or hematoma formation if pressure is not applied correctly.
Standard protocol requires applying firm, direct pressure with a sterile gauze pad for a minimum of 5 minutes.
This duration is extended to 10-15 minutes for patients on anticoagulant therapy to ensure adequate clotting.

Option B: Cleaning with an alcohol swab is a pre-procedure action to ensure asepsis and prevent infection.
Option C: A cloth piece is non-sterile and does not provide the firm, localized pressure needed to control arterial bleeding. This action is both ineffective and poses an infection risk.
Option D: This option is incorrect because a correct and critical nursing action is listed as the first option.

Clinical Relevance

Nursing practice connection: Knowing Post-procedure care following Arterial Blood Gas (ABG) collection helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Proper post-ABG care is a critical nursing skill to prevent patient complications. Failure to apply adequate pressure can lead to a large, painful hematoma, arterial occlusion, nerve damage, or, in rare cases, compartment syndrome.
Patient assessment is crucial. Before the procedure, the nurse should perform the Allen test to confirm adequate collateral circulation to the hand.
What if? If the patient is on anticoagulant medication like heparin or warfarin, the risk of bleeding is much higher. In this case, the nurse must apply pressure for a longer duration, typically 10-15 minutes, and monitor the site more frequently for any signs of bleeding.

How to Approach the Question

Identify the key elements of the question: The action required is after an ABG sample from the radial artery.
Recall the anatomy and physiology: The radial artery is a high-pressure vessel, unlike a vein used for routine blood draws.
Prioritize nursing actions based on safety. The most immediate risk after puncturing a high-pressure artery is bleeding.
Evaluate the options in the context of this risk: 'Putting pressure on the site' directly addresses the primary risk of hemorrhage.
Differentiate the timing of other actions: 'Cleaning with alcohol' is a pre-procedure step.
Eliminate inadequate options: 'Covering with a cloth-piece' is neither sterile nor effective for applying pressure. This leads to the conclusion that applying pressure is the only correct post-procedure action listed.

Concept Tested & Keywords

Concept Tested: Post-procedure care following Arterial Blood Gas (ABG) collection.
Stem keywords: nursing action, after taking ABG sample, radial artery
Lead-in keywords: appropriate