Exam 1 - Ch 11, 12 (sepsis, CV surgery) (ch 16: DIC)
Lactate
0.5-1.6
A patient is admitted with an angina attack. The nurse anticipates which drug regimen to be initiated? a. ACE inhibitors and diuretics b. Morphine and oxygen c. Nitroglycerin, oxygen, and beta-blockers d. Statins, bile acid, and nicotinic acid
C
A patient has been prescribed nitroglycerin in the ED for chest pain. In taking the health history, the nurse will be sure to verify whether the patient has taken medications prior to admission for: a. Erectile dysfxn b. Prostate enlargement c. Asthma d. PVD
A
BUN
10-20
AST
10-40
Sodium
135-145
Potassium
3.5-5
PaCO2
35-45
A patient is admitted to the CCU with an acute anterior MI. The nurse assesses the patient to be diaphoretic and tachypneic, with bilateral crackles throughout both lung fields. Following insertion of a pulmonary artery catheter by the physician, which hemodynamic values is the nurse most likely to assess? a. High pulmonary artery diastolic pressure and low CO b. Low PAOP and low CO c. Low SVR and high CO d. Normal CO and low SVR
A
The ED nurse admits a patient following a motor vehicle collision. Vital signs include BP 70/50, HR 140, RR 36, temp 101° F and SpO2 95% on 3L of O2 per nasal cannula. Laboratory results include hemoglobin 6.0, hematocrit 20%, and K+ 4.0. Based on this assessment, what is most important for the nurse to include in the patient's plan of care? a. Insertion of an 18-gauge peripheral IV b. Application of cushioned heel protectors c. Implementation of fall precautions d. Implementation of universal precautions
A
The nurse is caring for a patient admitted with cardiogenic shock. PAOP 18, cardiac index (CI) 1.0. What is the priority pharmacological intervention? a. Dobutamine (Dobutrex) b. Furosemide (Lasix) c. Phenylephrine (Neo-Synephrine) d. Sodium nitroprusside (Nipride)
A
The nurse is caring for a patient following insertion of an intraaortic balloon pump (IABP) for cardiogenic shock unresponsive to pharmacotherapy. Which hemodynamic parameter best indicates an appropriate response to therapy? a. Cardiac index (CI) of 2.5 L/min/m2 b. Pulmonary artery diastolic pressure of 26 mm Hg c. PAOP 22 mm Hg d. SVR 1600 dynes/sec/cm-5
A
The nurse is caring for a patient in cardiogenic shock who is being treated with an intraaortic balloon pump (IABP). The family inquires about the primary reason for the device. What is the best statement by the nurse to explain the IABP? a. "The action of the machine will improve blood supply to the damaged heart." b. "The machine will beat for the damaged heart with every beat until it heals." c. "The machine will help cleanse the blood of impurities that might damage the heart." d. "The machine will remain in place until the patient is ready for a heart transplant."
A
The nurse is caring for a patient in septic shock, BP 105/60, HR 110, RR 32, SpO2 95% on 45% supplemental O2 via Venturi mask, temp 102° F. The physician orders stat administration of an antibiotic. Which additional physician order should the nurse complete first? a. Blood cultures b. Chest x-ray c. Foley insertion d. Serum electrolytes
A
While monitoring a patient for signs of shock, the nurse understands which system assessment to be of priority? a. CNS b. GI system c. Renal system d. Respiratory system
A
Identify the priority interventions for managing symptoms of an AMI in the ED. (Select all that apply). a. Administration of morphine b. Administration of nitroglycerin (NTG) c. Dopamine infusion d. O2
A B D
Which statements are true regarding the symptoms of an AMI? (Select all that apply.) a. Dysrhythmias are common occurrences b. Men have more atypical symptoms than women c. Midsternal chest pain is a common presenting symptom d. Some patients are asymptomatic
A C D
A patient with coronary artery disease is having a cardiac evaluation to assess for possible valvular disease. Which study best identifies valvular function and measures the size of the cardiac chambers? a. 12-lead EKG b. Cardiac cath c. Echocardiogram d. Electrophysiology study
C
10 minutes following administration of an antibiotic, the nurse assesses a pt to have edematous lips, hoarseness, and expiratory stridor. BP 70/40, HR 130 bpm, RR 36 breaths/min. What is the priority intervention? a. Diphenhydramine (Benadryl) 50 mg IV b. Epinephrine 3 to 5 mL of a 1:10,000 solution IV c. Methylprednisolone (Solu-Medrol) 125 mg IV d. Ranitidine (Zantac) 50 mg IV
B
The nurse has just completed an infusion of a 1000 mL bolus of 0.9% NS in a pt with severe sepsis. One hour later, which lab result requires immediate nursing action? a. Creatinine 1.0 mg/dL b. Lactate 6 mmol/L c. Potassium 3.8 mEq/L d. Sodium 140 mEq/L
B
The nurse is administering IV norepinephrine at 5 mcg/kg/min via a 20-gauge peripheral IV. What assessment finding requires immediate action by the nurse? a. BP 100/60 b. Swelling at the IV site c. HR 110 d. CVP 8
B
The nurse is caring for a 70-kg patient in hypovolemic shock. Upon initial assessment, the nurse notes a BP 90/50, HR 125, RR 32, CVP/RAP 3, and UO 5 mL during the past hour. Following physician rounds, the nurse reviews the orders and questions which order? a. Acetaminophen 650 mg suppository PRN q6 for pain b. Titrate dopamine IV for SBP<90. c. Neuro assessment q4 for the next 24 hours d. Furosemide 20 mg IV q4 for CVP>20.
B
The nurse is caring for a patient in cardiogenic shock experiencing chest pain. Hemodynamic values assessed by the nurse include a cardiac index (CI) of 2.5, HR 70, SVR 2200. Upon review of physician orders, which order is most appropriate for the nurse to initiate? a. Furosemide 20 mg IV q4 PRN for CVP>20 b. Nitroglycerin IV titrated at 5-10 mcg/min PRN for chest pain c. Dobutamine IV 2-20 mcg/kg/min PRN for CI < 2 d. Dopamine IV at 5-10 mcg/kg/min to maintain a SBP of at least 90
B
Which nursing interventions would be appropriate after angioplasty? (Select all that apply.) a. Elevate the HOB 45 degrees for 6 hours b. Assess pedal pulses on the involved limb q15 min for 2 hrs c. Monitor the vascular hemostatic device for signs of bleeding d. Instruct the pt bend his/her knee q15 min while the sheath is in place
B C
The cardiologist has told the patient and family that the diagnosis is hypertrophic cardiomyopathy. Later they ask the nurse what the patient did wrong to cause this condition. The nurse explains: a. "This is a result of a high-cholesterol diet and poor exercise habits." b. "The heart has not been getting enough aerobic exercise and has developed this condition. In cardiac rehabilitation they will work with the patient to strengthen his heart through special exercises." c. "This is an inherited condition. You should give serious consideration to having family members screened for it." d. "This is a result of clot formation in the blood vessels in the heart. We will need to use medications to reduce the risk of further clotting."
C
The nurse is caring for a patient in cardiogenic shock who is being treated with an infusion of dobutamine. The physician's order calls for the nurse to titrate the infusion to achieve a cardiac index of >2.5 L/min/m2. The nurse measures a CO, and the calculated cardiac index is 4.6 L/min/m2. What is the best action by the nurse? a. Obtain a stat serum K+ level. b. Order a stat 12-lead EKG. c. Reduce the rate of dobutamine. d. Assess the patient's hourly UO.
C
The nurse is starting to administer a unit of packed red blood cells to a pt in hypovolemic shock secondary to hemorrhage. BP 60/40, HR 150, RR 42, temp 100.6° F. What is the best action by the nurse? a. Administer blood transfusion over at least 4 hrs. b. Notify the physician of the elevated temp c. Titrate rate of blood administration to patient response d. Notify the physician of the patient's HR
C
While instructing a patient on what occurs with a MI, the nurse plans to explain which process? a. Coronary artery spasm b. Decreased blood flow (ischemia) c. Death of cardiac muscle from lack of O2 (tissue necrosis) d. Sporadic decrease in O2 to the heart (transient O2 imbalance)
C
During the initial stages of shock, what are the physiological effects of decreased CO? a. Arterial vasodilation b. High UO c. Increased PNS stimulation d. Increased SNS stimulation
D
Percutaneous coronary intervention is contraindicated for patients with lesions in which coronary artery? a. Right coronary artery b. Left coronary artery c. Circumflex d. Left main coronary artery
D
The nurse has been administering 0.9% NS IVF as part of early goal-directed therapy protocols in a pt with severe sepsis. To evaluate the effectiveness of fluid therapy, which physiological parameters would be most important for the nurse to assess? a. Breath sounds and capillary refill b. BP and oral temp c. Oral temp and capillary refill d. RAP/CVP and urine output
D
The nurse is administering crystalloid and colloid IVF as part of fluid resuscitation for a patient in severe sepsis. What findings assessed by the nurse indicate an appropriate response to therapy? a. Normal body temp b. Balanced I&O c. Adequate pain management d. UO of 0.5 mL/kg/hr
D
The nurse is caring for a patient admitted with the early stages of septic shock. The nurse assesses the patient to be tachypneic, RR 32. ABG on admission are pH 7.50, CO2 28, HCO3 26. Which diagnostic study result reviewed by the nurse indicates progression of the shock state? a. pH 7.40, CO2 40, HCO3 24 b. pH 7.45, CO2 45, HCO3 26 c. pH 7.35, CO2 40, HCO3 22 d. pH 7.30, CO2 45, HCO3 18
D
The nurse is caring for a patient in the early stages of septic shock. The patient is slightly confused and flushed, with bounding peripheral pulses. Which hemodynamic values is the nurse most likely to assess? a. High PAOP and high CO b. High SVR and low CO c. Low PAOP and low CO d. Low SVR and high CO
D
The nurse is caring for a patient with severe sepsis. BP 80/50, HR 120, RR 28, temp 102° F, CVP/RAP 1. Assuming physician orders, which intervention should the nurse carry out first? a. Acetaminophen suppository b. Blood cultures from 2 sites c. IV antibiotic administration d. Isotonic fluid challenge
D
Hemoglobin
Males 13-18 Females 12-16
Hematocrit
Males 42-52% Females 35-47%
Creatinine
0.7-1.4
RAP/CVP
2-6
HCO3
22-26
pH
7.35-7.45
PaO2
80-100
LDH
90-176
Chloride
96-106
A patient is admitted to the ED with clinical indications of an AMI. Symptoms began 3 hours ago. The facility does not have the capability for percutaneous coronary intervention. Given this scenario, what is the priority intervention in the treatment and nursing management of this patient? a. Administer thrombolytic therapy unless contraindicated b. Diurese aggressively and monitor daily weight c. Keep O2 at least 88% d. Maintain HR>100
A
A patient presents to the ED complaining of severe substernal chest pressure radiating to his left shoulder and back that started about 12 hrs ago. The patient delayed coming to the ED since he was hoping the pain would go away. The patient's 12-lead ECG shows ST-segment depression in the inferior leads. Troponin and CK-MB are both elevated. The hospital does not have the capability for percutaneous coronary intervention. Thrombolysis is a possible treatment. Based on these data, the nurse understands that? a. The patient is not a candidate for thrombolysis. b. The patient's history makes him a good candidate for thrombolysis. c. Thrombolysis is appropriate for a candidate having a non-Q wave MI. d. Thrombolysis should be started immediately.
A
A patient presents to the ED with chest pain that he has had for the past 2 hrs. He is nauseous and diaphoretic, and his skin is dusky in color. The EKG shows ST elevation in leads II, III, and aVF. Which therapeutic intervention would the nurse question? a. Emergent pacemaker insertion b. Emergent percutaneous coronary intervention c. Emergent thrombolytic therapy d. Immediate coronary artery bypass graft surgery
A
After receiving a handoff report from the night shift, the nurse completes the AM assessment of a patient with severe sepsis. BP 95/60, HR 110, RR 32, SpO2 96% on 45% oxygen via Venturi mask, temp 101.5° F, CVP/RAP 2, UO 10 mL for the past hour. The nurse initiates which active physician order first? a. Administer 500 mL 0.9% NS q4 hrs PRN for CVP < 5 b. Increase O2 to maintain SpO2>94% c. Administer 40 mg furosemide IV PRN for UO<30 mL/hr d. Administer acetaminophen 650 mg rectal suppository PRN for temp>101° F
A
The nurse is caring for a mechanically ventilated patient following insertion of a left subclavian central venous catheter (CVC). What action by the nurse best protects against the development of a central line-associated bloodstream infection (CLABSI)? a. Documentation of insertion date b. Elevation of the head of the bed c. Assessment for weaning readiness d. Appropriate sedation management
A
The nurse is caring for a pt with hypovolemic shock. The nurse palpates thready brachial pulses but is unable to auscultate a BP. What is the best nursing action? a. Assess the BP by Doppler. b. Estimate the SBP as 60 mm Hg. c. Obtain an electronic BP monitor. d. Record the BP as "not assessable."
A
The nurse is caring for an 18 yo athlete with possible C5 injury following a diving accident. The nurse assesses a BP 70/50, HR 45 bpm, and RR 26 breaths/min. The patient's skin is warm and flushed. What is the best interpretation of these findings by the nurse? a. The pt is developing neurogenic shock. b. The pt is experiencing an allergic reaction. c. The pt most likely has an elevated temp. d. The VS are normal for this pt.
A
The nurse is providing care to a patient on fibrinolytic therapy. Which statement from the patient warrants further assessment and intervention by the critical care nurse? a. "My back is killing me!" b. "There is blood on my toothbrush!" c. "Look at the bruises on my arms!" d. "My arm is bleeding where my IV is!"
A
The patient is admitted with a suspected AMI. In assessing the 12-lead ECG changes, which findings would indicate to the nurse that the patient is in the process of an evolving Q wave MI? a. ST-elevation and elevated CPK-MB or troponin levels b. ST-depression and elevated total CPK c. ST-depression and normal cardiac enzymes d. Q wave on ECG with normal enzymes and troponin levels
A
The patient presents to the ED with severe chest discomfort. He is taken for cardiac cath and angiography that shows 80% occlusion of the left main coronary artery. Which procedure will be most likely followed? a. CABG surgery b. Intracoronary stent placement c. Percutaneous transluminal coronary angioplasty d. Transmyocardial revascularization
A
Which clinical manifestations are indicative of right ventricular failure? (Select all that apply.) a. JVD b. Peripheral edema c. Crackles audible in the lungs d. Weak peripheral pulses
A B
The patient has been in chronic HF for the past 10 yrs. He has been treated with beta-blockers, ACE inhibitors, and diuretics. His symptoms have recently worsened, and he presents to the ED with severe SOB and crackles throughout his lung fields. His respirations are labored and ABGs show that he is at risk for respiratory failure. Which of the following therapies may be used for acute, short-term management of the patient? (Select all that apply). a. Dobutamine b. Intraaortic balloon pump c. Nesiritide (Natrecor) d. Ventricular assist device
A B C
The patient's husband tells the nurse, "We didn't think she was having a heart attack because the pain was in her neck and back." The nurse explains: (Select all that apply.) a. "Pain can occur anywhere in the chest, neck, arms, or back. Don't hesitate to call the emergency medical services if you think it's a heart attack." b. "For many people chest pain from a heart attack occurs in the center of the chest, behind the breastbone." c. "The sooner the patient can get medical help, the less damage is likely to occur in case of a heart attack." d. "You need to make sure it's a heart attack before you call the emergency response personnel."
A B C
A patient is admitted with an AMI. The nurse monitors for which potential complications? (Select all that apply.) a. Cardiac dysrhythmias b. Heart failure c. Pericarditis d. Ventricular rupture
A B C D
Accepted treatments for DIC may require: (Select all that apply) a. platelet infusions b. administration of fresh frozen plasma c. cryoprecipitate d. packed RBCs e. heparin
A B C D
The nurse is caring for a young adult pt in shock. The nurse understands which assessment findings best assess tissue perfusion in a patient in shock? (Select all that apply.) a. BP b. HR c. LOC d. Pupil response e. RR f. UO
A C F
A patient was admitted in terminal HF and is not eligible for transplant. The family wants everything possible done to maintain life. Which procedure might be offered to the patient for this condition to increase the patient's quality of life? a. Intraaortic balloon pump (IABP) b. Left ventricular assist device (LVAD) c. Nothing, because the patient is in terminal heart failure d. Nothing additional; medical management is the only option
B
An essential aspect of teaching that may prevent recurrence of HF is: a. notifying the physician if a 2-lb weight gain occurs in 24 hours b. compliance with diuretic therapy c. taking nitroglycerin if chest pain occurs d. assessment of an apical pulse
B
The nurse has just completed administration of a 1000-L bolus of 0.9% NS. The nurse assesses the pt to be slightly confused, with MAP 50, HR 110, UO 10 mL for the past hour, and CVP/RAP 3. What is the best interpretation of these results by the nurse? a. Patient response to therapy is appropriate. b. Additional interventions are indicated. c. More time is needed to assess response. d. Values are normal for the patient condition.
B
The nurse is caring for a patient with severe sepsis who was resuscitated with 3000 mL LR solution over the past 4 hours. Morning lab results show a hemoglobin of 8 and hematocrit of 28%. What is the best interpretation of these findings by the nurse? a. Blood transfusion with packed red blood cells is required b. Hemoglobin and hematocrit results indicate hemodilution c. Fluid resuscitation has resulted in fluid volume overload d. Fluid resuscitation has resulted in third spacing of fluid
B
The patient has undergone open chest surgery for coronary artery bypass grafting. One of the nurse's responsibilities is to monitor the patient for which common postoperative dysrhythmia? a. Second degree heart block b. Atrial fibrillation or flutter c. Ventricular ectopy d. Premature junctional contractions
B
The patient is admitted with an AMI. 3 days later the nurse is concerned that the patient may have a papillary muscle rupture. Which assessment data may indicate a papillary muscle rupture? a. Gallop rhythm b. Murmur c. S1 heart sound d. S3 heart sound
B
The patient is admitted with anemia and active bleeding. The nurse suspects DIC. Definitive diagnosis of DIC is made by evidence of: a. a decrease in fibrin degradation products b. an increased D-dimer level c. thrombocytopenia d. low fibrinogen levels
B
The patient's wife is confused about the scheduling of a stent insertion. She says that she thought the angioplasty was surgery to fix her husband's heart problem. The nurse explains to her: a. "The angioplasty was a failure, and so this procedure has to be done to fix the heart vessel." b. "The stent is inserted to enhance the results of the angioplasty, by helping to keep the vessel open and prevent it from closing again." c. "This procedure is being done instead of using clot-dissolving medication to help keep the heart vessel open." d. "The stent will remove any clots that are in the vessel and protect the heart muscle from damage."
B
The patient's wife is feeling overwhelmed and tells the nurse that she doesn't know if she can manage to cook different dinners for her husband and the rest of the family to satisfy his cholesterol-reducing diet. The nurse tells her: a. "It will be worth it to have him healthy, won't it?" b. "The low-cholesterol diet is one from which everyone can benefit." c. "A long as you change at least a few things in the diet, it will be okay." d. "You can go on the diet with him, and then just let the children eat whatever they want."
B
Which comment by the patient indicates a good understanding of her diagnosis of coronary heart disease? a. "I had a heart attack because I work too hard and it puts too much strain on my heart." b. "The pain in my chest gets worse each time it happens. I think that there is more damage to my heart vessels as time goes on." c. "If I change my diet and exercise more, I should get over this and be healthy." d. "What kind of pills can you give me to get me over this and back to my lifestyle?"
B
Which of the following cardiac diagnostic tests would include monitoring the gag reflex before giving the patient anything to eat or drink? a. Barium swallow b. Transesophageal echocardiogram c. MUGA scan d. Stress test
B
15 min after beginning a transfusion of O- blood to a patient in shock, the nurse assesses a drop in the patient's BP to 60/40, HR 135, RR 40, and temp 102° F. The nurse notes the new onset of hematuria in the patient's Foley catheter. What are the priority nursing actions? (Select all that apply.) a. Administer acetaminophen b. Document the patient's response c. Increase the rate of transfusion d. Notify the blood bank e. Notify the physician f. Stop the transfusion
B D E F
72 yo woman is brought to the ED by her family. The family states that she's "just not herself." Her respirations are slightly labored, and her heart monitor shows sinus tachycardia (HR 110) with frequent PVCs. She denies any chest pain, jaw pain, back discomfort, or nausea. Her troponin levels are elevated, and her 12-lead ECG shows elevated ST segments in leads II, III, and AVF. The nurse knows that these symptoms are most likely associated with which diagnosis? a. Hypokalemia b. Non-Q wave MI c. Silent MI d. Unstable angina
C
A patient is admitted after collapsing at the end of a summer marathon. She is lethargic, HR 110, RR 30, BP 78/46. The nurse anticipates administering which therapeutic intervention? a. Human albumin infusion b. Hypotonic saline solution c. Lactated Ringer's bolus d. Packed red blood cells
C
A patient is admitted with an AMI. The nurse knows that an ACE inhibitor should be started within 24 hrs to reduce the incidence of which process? a. Myocardial stunning b. Hibernating myocardium c. Myocardial remodeling d. Tachycardia
C
A patient is admitted with the diagnosis of unstable angina. The nurse knows that the physiological mechanism present is most likely which of the following? a. Complete occlusion of a coronary artery b. Fatty streak within the intima of a coronary artery c. Partial occlusion of a coronary artery with a thrombus d. Vasospasm of a coronary artery
C
The nurse is assessing a patient with left-sided HF. Which symptom would the nurse expect to find? a. Dependent edema b. Distended neck veins c. Dyspnea and crackles d. N/V
C
The nurse is caring for a patient admitted following a motor vehicle crash. Over the past 2 hrs, the patient has received 6 units of packed red blood cells and 4 units of fresh frozen plasma by rapid infusion. To prevent complications, what is the priority nursing intervention? a. Administer pain medication. b. Turn patient q2 hours. c. Assess core body temperature. d. Apply bilateral heel protectors.
C
The nurse is caring for a patient in spinal shock. Vital signs include BP 100/70, HR 70 bpm, RR 24, O2 95% on room air, and an oral temp 96.8° F. Which intervention is most important for the nurse to include in the patient's plan of care? a. Administration of atropine sulfate (Atropine) b. Application of 100% oxygen via facemask c. Application of slow rewarming measures d. Infusion of IV phenylephrine (Neo-Synephrine)
C
The nurse is caring for a pt admitted to the CCU 48 hours ago with severe sepsis. As part of this patient's care plan, what intervention is most important for the nurse to discuss with the multidisciplinary care team? a. Frequent turning b. Monitoring I&O c. Enteral feedings d. Pain management
C
The patient is admitted with recurrent SVT that the cardiologist believes to be related to an accessory conduction pathway or a reentry pathway. The nurse anticipates which procedure to be planned for this patient? a. ICD placement b. Permanent pacemaker insertion c. Radiofrequency catheter ablation d. Temporary transvenous pacemaker placement
C
The patient presents to the ED with sudden severe sharp chest discomfort radiating to his back and down both arms, as well as numbness in his left arm. While taking the patient's vital signs, the nurse notices a 30-point discrepancy in SBP between the right and left arm. Based on these findings, the nurse should: a. contact the physician and report the cardiac enzyme results b. contact the physician and prepare the patient for thrombolytic therapy c. contact the physician immediately and begin prepping the patient for surgery d. give the patient aspirin and heparin
C
The patient's wife asks the nurse if the angioplasty will remove all the buildup in the vessel walls so that the patient will be healthy again. The nurse explains: a. "The operation will remove all of the plaque, and if your husband exercises and diets he will be free of cardiac problems." b. "The surgery will remove all the buildup, but it will reaccumulate and he will probably need this surgery again this time next year." c. "The best outcome will be if 20% to 50% of the diameter of the vessel can be restored. Your husband will need to diet and exercise carefully to avoid further cardiac risk." d. "The surgeon will only be able to get 5% to 10% of the plaque, but this will bring about marked relief of your husband's symptoms."
C
The physician orders a pharmacological stress test for a patient with activity intolerance. The nurse would anticipate that the drug of choice would be a. Dopamine b. Dobutamine c. Adenosine d. Atropine
C
Which patient being cared for in the ED is most at risk for developing hypovolemic shock? a. A pt with abdominal pain and an elevated WBC count b. A pt with a temp of 102° F and a general dermal rash c. A pt with a 2-day hx of N/V/D d. A pt with slight rectal bleeding from inflamed hemorrhoids
C
AMI can be classified as which of the following? (Select all that apply.) a. Angina b. Nonischemic c. Non-Q wave d. Q wave
C D
A patient has elevated blood lipids. The nurse anticipates which classification of drugs to be prescribed for the patient? a. Bile acid resins b. Nicotinic acid c. Nitroglycerin d. Statins
D
A patient is admitted to the CCU following CABG surgery. Two hours post-op, the: HR 120; BP 70/50; pulmonary artery diastolic pressure 2; CO 4 L/min; UO 250 mL/hr; chest drainage 200 mL/hr. What is the best interpretation by the nurse? a. Values are within normal limits. b. Patient is at risk for cardiogenic shock c. Patient is at risk for fluid volume overload d. Patient is at risk for hypovolemic shock
D
