SOLE Chapter 8 TB
The charge nurse has a Vigielo pulse contour cardiac output monitoring system available for use in the surgical intensive care unit. For which patient is the use of this device most appropriate? A. A patient with a HX of aortic insufficiency admitted with a post-op myocardial infarction B. A mechanically ventilated patient with cardiogenic shock being treated with an intra-aortic balloon pump C. A patient with a HX of a-fib having frequent episodes of paroxysmal supraventricular tachycardia D. A mechanically ventilated patient admitted following repair of an acute bowel obstruction
A mechanically ventilated patient admitted following repair of an acute bowel obstruction Pulse contour analysis systems provide stroke volume variation and pulse pressure variation data and are better predictors of fluid responsiveness in mechanically ventilated patients.
The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a BP of 85/40, HR 125, resp rate 35, arterial oxygen saturation (SpO2) of 90% on a 50% Venturi mask. Hemodynamic values include a cardiac output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pressure (PAOP) of 3 mm Hg. The nurse questions which of the following MD orders? A. Titration of supplemental oxygen to achieve a SpO2 > 94% B. Infuse 500 mL of 0.9% NS over 1 hour C. Obtain arterial blood gas and serum electrolytes D. Administer furosemide (Lasix) 20mg IV
Administer furosemide (Lasix) 20 mg IV
The nurse is caring for a 70-kg pt in septic shock with a pulmonary artery catheter. Which hemodynamic value indicates an appropriate response to therapy aimed at enhancing oxygen delivery to the organs and tissues? A. Arterial lactate level of 1.0 mEq/L B. Cardiac output of 2.5 L/min C. Mixed venous (SvO2) of 40% D. Cardiac index of 1.5 L/min/m2
Arterial lactate level of 1.0 mEq/L
The nurse is caring for a patient with an arterial monitoring system. The nurse assesses the patients noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood measurement via an intra-arterial catheter in the same arm is assessed by the nurse to be 108/70. What is the best action by the nurse? A. Activate the rapid response system B. Place the patient in trendelenburg position C. Assess the cuff for proper arm size D. Administer 0.9% normal saline bolus
Assess the cuff for proper arm size
The nurse is preparing to measure the thermodilution cardiac output (TdCO) in a patient being monitored with a pulmonary artery cath. Which action by the nurse best ensures the safety of the patient? A. Ensure the transducer system is zero referenced at the level of the phlebostatic axis B. Avoid infusing vasoactive agents in the port used to obtain the TdCO measurement C. Maintain a pressure of 300 mmHg on the flush solution using a pressure bag D. Limit the length of the non complaint pressure tubing to a max of 48 inches
Avoid infusing vasoactive agents in the port used to obtain the TdCO measurement
The nurse is caring for a 100 kg pt being monitored with pulmonary artery (PA) catheter. The nurse assesses a BP 90/60, HR 110 bpm, resp rate 36, o2 89% on 3 L via NC. Bilateral crackles are audible upon auscultation. Which hemodynamic value requires immediate action by the nurse? A. Cardiac index (CI) of 1.2 L/min/m3 B. Cardiac output (CO) of 4 L/min C. Pulmonary vascular resistance (PVR) of 80 dynes/sec/cm-5 D. Systemic vascular resistance (SVR) of 1800 dynes/sec/cm-5
Cardiac Index (CI) of 1.2 L/min/m3 This CI with other assessment findings indicate a low cardiac output with fluid overload (bil. crackles).
Upon entering the room of a patient with a right radial arterial line, the nurse assesses the waveform to be slightly dampened and notices blood to be backed up into the pressure tubing. What is the best action by the nurse? A. Check the inflation volume of the flush system pressure bag B. Disconnect the flush system from the arterial line catheter C. Zero reference the transducer system at the phlebostatic axis D. Reduce the number of stopcocks in the flush system tubing
Check the inflation volume of the flush system pressure bag (should be 300 mmHg to ensure constant flow of fluid thru the system to prevent backward flow of blood into the system tubing).
The nurse is caring for a patient with an admitting DX of congestive heart failure. While attempting to obtain a pulmonary artery occlusion pressure in the supine position, the patient becomes anxious and tachypneic. What is the best action by the nurse? A. Limit the patients supine position to no more than 10 seconds B. Administer anxiety meds while recording the pressure C. Encourage the patient to take slow deep breaths while supine D. Elevate the HOB 45 degrees while recording pressure
Elevate the HOB 45 degrees while recoding pressure
The nurse is caring for a pt with a left radial arterial line, and a pulmonary artery catheter inserted into the right subclavian vein. Which action by the nurse best ensures the safety of the patient being monitored with invasive hemodynamic monitoring lines? A. Document all waveform values B. Limit the pressure tubing length C. Zero reference the system daily D. Ensure alarm limits are turned on
Ensure alarm limits are turned on
The nurse is caring for a pt who has had an arterial line inserted. To reduce the risk of complications, what is the priority nursing intervention? A. Apply a pressure dressing to the insertion site B. Ensure all tubing connections are tightened C. Obtain a portable x-ray to confirm placement D. Restrain the affected extremity for 24 hours
Ensure all tubing connections are tightened Loose connections in hemodynamic monitoring tubing can lead to hemorrhage, a major complication of arterial pressure monitoring.
During insertion of a pulmonary artery cath, the MD asks the nurse to assist by inflating the balloon with 1.5 mL of air. A the MD advances the cath, the nurse notices premature ventricular contractions on the monitor. What is the best action by the nurse? A. Deflate the balloon while slowly withdrawing the cath B. Instruct the patient to cough and deep-breathe forcefully C. Inflate the catheter balloon with an additional 1 mL of air D. Ensure lidocaine hydrochloride (IV) is immediately available
Ensure lidocaine hydrochloride (IV) is immediately available During the insertion of the pulmonary artery cath, ventricular dysrhythmias may occur as the cath passes thru the right ventricle. TX with lidocaine hydrochloride may be necessary to suppress the irritated ventricle and should be readily available.
The nurse is preparing to obtain a pulmonary artery occlusion pressure (PAOP) reading for a pt who is mechanically ventilated. Ensuring that the air-fluid interface is at the level of the phlebostatic axis, what is the best nursing action? A. Place the patient in the supine position and record the PAOP immediately after exhalation B. Place the patient in the supine position and document the average PAOP obtained after three measurements C. Place the patient with the HOB elevated 30 degrees and document the average PAOP pressure obtained D. Place the patient with the HOB elevated 30 degrees and record the PAOP just before the increase in pressure during inhaltion
Place the patient with the HOB elevated 30 degrees and record the PAOP just before the increase in pressure during inhaltion Pressure are highest when measured at end exhalation in the spontaneously breathing patient. In mechanically ventilated pts, pressures increase with inhalation and decrease with exhalation. Measurements are obtained just before the increase in pressure during inhalation. Supine positioning is contraindicated in the mechanically ventilated patient and HOB should be elevated to 30 degrees.
The nurse is caring for a mechanically ventilated patient being monitored with a left radial arterial line. During the inspiratory phase of ventilation, the nurse assesses a 20 mmHg decrease in arterial blood pressure. What is the best interpretation of this finding by the nurse? A. The mechanical ventilation is malfunctioning B. The patient may require fluid resuscitation C. The arterial line may need to be replaced D. The left limb may have reduced perfusion
The patient may require fluid resuscitation
While caring for a patient with a pulmonary artery cath, the nurse notes the pulmonary artery occlusion pressure (PAOP) to be significantly higher than the previously recorded values. The nurse assesses respiration's to be unlabored at 16 breaths/min, o2 sats 98% on 3L via NC, and lungs clear to auscultation bilaterally. What is the priority action? A. Increase supplemental oxygen & notify respiratory therapy B. Notify the MD immediately of the assessment findings C. Obtain a STAT chest x-ray film to verify proper cath placement D. Zero reference and level the cath at the phlebostatic axis
Zero reference and level the catheter at the phlebostatic axis A hemodynamic value not supported by clinical assessment by nurse should be treated as questionable. To ensure the accuracy of hemodynamic readings, the cath transducer system must be leveled at phlebostatic axis and zero referenced.
The nurse returns from the cardiac cath lab with a patient following insertion of a pulmonary artery catheter and assists in transferring the patient from the stretcher to the bed. Prior to obtaining a cardiac output, which action is most important for the nurse to complete? A. Document a pulmonary artery catheter occlusion pressure B. Zero reference the transducer system at the phlebostatic axis C. Inflate the pulmonary artery cath balloon with 1 ml air D. Inject 10mL of 0.9% normal saline into the proximal port
Zero reference the transducer system at the phlebostatic axis
Which of the following situations may result in a low cardiac output and low cardiac index? (SATA) A. Exercise B. Hypovolemia C. Myocardial infarction D. Shock
- hypovolemia - myocardial infarction - shock
The nurse is preparing for insertion of a pulmonary artery cath (PAC). During insertion, what are the priority nursing actions? (SATA) A. Allay the patients anxiety by providing info about the procedure B. Ensure that a sterile field is maintained during the insertion procedure C. Inflate the balloon during the procedure when indicated by the MD D. Monitor the patients cardiac rhythm throughout the entire procedure E. Obtain informed consent by informing the patient of procedural risks
- Allay the patients anxiety by providing info about the procedure - Ensure that a sterile field is maintained during the insertion procedure - Inflate the balloon during the procedure when indicated by the MD - Monitor the patients cardiac rhythm throughout the entire procedure
Which nursing actions are most important for a patient with a right radial arterial line? (SATA) A. Checking circulation to the right hand every 2 hours B. Maintaining a pressurized flush solution to the arterial line setup C. Monitoring the waveform on the monitor for dampening D. Restraining all four extremities with soft limb restraints
- checking circulation to the right hand every 2 hours - maintaining a pressurized flush solution to the arterial line setup - monitoring the waveform on the monitor for dampening
The nurse is preparing to obtain a right atrial pressure (RAP/CVP) reading. What are the most appropriate nursing actions? (SATA) A. Compare measured pressure with other physiological parameters B. Flush the central venous cath with 20 mL of sterile saline C. Inflate the balloon with 3mL of air and record the pressure tracing D. Obtain the right atrial pressure measurement during end exhalation E. Zero reference the transducer system at the level of the phlebostatic axis
- compare measured pressure with other physiological parameters - obtain right atrial pressure measurement during end exhalation - zero reference the transducer system at the level of the phlebostatic axis
When performing an initial pulmonary artery occlusion pressure (PAOP), what are the best nursing actions? (SATA) A. Inflate the balloon for no more than 8 to 10 seconds while noting the waveform change B. Inflate the balloon with air, recording the volume necessary to obtain a reading C. Maintain the balloon in the inflated position or 8 hours following insertion D. Zero reference and level the air-fluid interface of the transducer at the level of the phlebostatic axis
- inflate the balloon for no more than 8 to 10 seconds, while noting the waveform change - inflate the balloon with air, recording the volume necessary to obtain a reading - zero reference and level the air-fluid interface of the transducer at the level of the phlebostatic axis
The charge nurse is supervising the care of four critical care patients being monitored using invasive hemodynamic modalities. Which patient should the charge nurse evaluate first? A. A patient in cardiogenic shock with a cardiac output (CO) of 2.0 L/min B. A patient with a pulmonary artery systolic pressure (PAP) of 20 mmHg C. A hypovolemic patient with a central venous pressure (CVP) of 6 mmHg D. A patient with a pulmonary artery occlusion pressure (PAOP) of 10 mmHg
A patient in cardiogenic shock with a cardiac output (CO) of 2.0 L/min
The physician writes an order to discontinue a patients left radial arterial line. When discontinuing the patients invasive line, what is the priority nursing action? A. Apply an air occlusion dressing to insertion site B. Apply pressure to the insertion site for 5 minutes C. Elevate the affected limb on pillows for 24 hours D. Keep the patients wrist in a neutral position
Apply pressure to insertion site for 5 minutes Adequate pressure must be applied for at least 5 minutes to ensure adequate hemostasis
While caring for a patient with a small bowel obstruction, the nurse assesses a pulmonary artery occlusion pressure (PAOP) of 1 mm Hg and hourly urine output of 5 mL. The nurse anticipates which therapeutic intervention? A. Diuretics B. Intravenous fluids C. Negative inotropic agents D. Vasopressors
Intravenous fluids Low PAOP usually indicates volume depletion, so IV fluids would be indicated.
After pulmonary artery cath insertion, the nurse assess a pulmonary artery pressure of 45/25, a pulmonary artery occlusion pressure (PAOP) of 20 mm Hg, a cardiac output (CO) of 2.6 L/min, and a cardiac index (CI) of 1.9 L/min/m2. Which physician order is of the highest priority? A. Apply 50% oxygen via venturi mask B. Insert and indwelling urinary catheter C. Begins a dobutamine (Dobutrex) infusion D. Obtain stat cardiac enzymes and troponin
Begin a dobutamine (Dobutrex) infusion The pulmonary pressures are higher than normal, indicated elevated preload, and CI and CO values are low. Dobutrex infusion will improve cardiac output, possibly reducing PAOP.
A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse assess vital signs to be BP 80/50, HR 135, resp rate 36, cardiac output (CO) of 2 L/min, systemic vascular resistance (SVR) of 3000 dynes/sec/cm-5, and a hematocrit of 20%. The nurse anticipates administration of which of the following therapies or medications? A. Blood transfusion B. Furosemide (Lasix) C. Dobutamine (Dobutrex) infusion D. Dopamine hydrochloride (Dopamine) infusion
Blood transfusion Both hemodynamic parameters and the reported hematocrit value indicate hypovolemia and blood loss requiring volume resuscitation with blood products.
Following insertion of a pulmonary artery catheter (PAC), the physician orders the nurse to obtain a blood sample for mixed venous oxygen saturation (SvO2). Which action by the nurse best ensures the obtained value is accurate? A. Zero referencing the transducer at the level of the phlebostatic axis following insertion B. Calibrating the system with a central venous blood sample and arterial blood gas value C. Ensuring patency of the cath using a 0.9% normal saline solution pressured at 300 mg Hg D. Using non compliant pressure tubing that is no longer than 36 to 48 inches ans has minimal stopcocks
Calibrating the system with a central venous blood sample and arterial blood gas value
While inflating the balloon of the pulmonary artery catheter (PAC) with a 1.0 mL of air to obtain a pulmonary arter occlusion pressure (PAOP), the nurse encounters resistance. What is the best nursing action? A. Add an additional 0.5mL of air to the balloon and repeat the procedure B. Advance the catheter with the balloon deflated and repeat the process C. Deflate the balloon and obtain a chest x-ray study to determine line placement D. Lock the balloon in the inflated position and flush the distal port of the PAC with normal saline
Deflate the balloon and obtain a chest x-ray study to determine line placement Balloon inflation should never be forced because the PAC may have migrated further into the pulmonary artery, causing resistant to balloon inflation. Verification of proper line placement is warranted to avoid pulmonary artery rupture.
The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate action? A. Diminished breath sounds over left lung field B. Localized pain at catheter insertion site C. Measured central venous pressure of 5 mm Hg D. Slight bloody drainage around insertion site
Diminished breath sounds over left lung field Diminished breath sounds over the lung field on the same side of the line insertion site may be indicative of a pneumothorax.
The physician orders a pulmonary artery occlusive (PAOP) for a patient being monitored with a pulmonary artery catheter. Immediately after obtaining an occlusive pressure, the nurse notes the change in waveform indicated on the strip below. What are the best actions by the nurse? A. Turn the patient to the left side, obtain a stat portable chest x-ray B. Place the patient supine, repeat zero-referencing of the system C. Document the wedge pressure, continue monitoring the patient D. Perform an immediate dynamic response test, obtain a chest x-ray
Document the wedge pressure and continuing monitoring the patient
The nurse is caring for a mechanically ventilated patient with a pulmonary artery catheter who is receiving continuous enteral tube feedings. When obtaining continuous hemodynamic monitoring measurements, what is the best nursing action? A. Do not document hemodynamic values until the patient can be placed in the supine position B. Level and zero reference the air-fluid interface of the transducer with the patient in the supine position and record hey o dynamic values C. Level and zero reference the air-fluid interface of the transducer with the patients HOB elevated 30 degrees and record hemodynamic values D. Level and zero reference the air-fluid interface of the transducer with the patient supine in the side-lying position and record hemodynamic values
Level and zero reference the air-fluid interface of the transducer with the patients HOB elevated 30 degrees and record hemodynamic values Elevation of the HOB in an important intervention to prevent aspiration and ventilator- associated PNA.
The nurse is caring for a pt with a left subclavian central venous catheter (CVC) and a left radial arterial line. Which assessment finding by the nurse requires immediate action? A. A dampened arterial line waveform B. Numbness and tingling in the left hand C. Slight bloody drainage at subclavian insertion site D. Slight redness at subclavian insertion site
Numbness and tingling in the left hand This is the location of an arterial catheter, indicating possible neuromuscular compromise that requires immediate action.
The charge nurse is supervising care for a group of patients monitored with a variety of invasive hemodynamic devices. Which patient should the charge nurse evaluate first? A. Patient with a central venous pressure (RAP/CVP) of 6 mm Hg and 40mL of urine output in the past hour B. Patient with a left radial arterial line with a BP of 110/60 and slightly dampened arterial waveform C. Patient with a pulmonary artery occlusion pressure of 25 and an oxygen sat of 89% on 3 L via nasal cannula D. Patient with a pulmonary artery pressure of 25/10 and an oxygen sat of 94% on 2 L via nasal cannula
Patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen sat of 89% on 3 L via NC A high PAOP of 25 with low o2 sat of 89% is indicative of fluid volume overload and warrants priority action because pt is at risk for hypoxemia.
The nurse is caring for a patient following an insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best reduces the risk of catheter-related bloodstream infection (CRBSIs)? A. Review the daily necessity of the central venous catheter B. Cleanse the insertion site daily with isopropyl alcohol C. Change the pressurized tubing system and flush bag daily D. Maintain a pressure of 300 mm Hg on the flush bag
Review the daily necessity of the central venous catheter Duration of the cath is an independent risk factor for CRBSI, and removal of the cath when not needed to guide TX is associated with a reduction in mortality.
The nurse is educating a patients family member about a pulmonary artery catheter (PAC). Which statement by the family member best indicates understanding of the purpose of the PAC? A. The cath will provide multiple sites to give IV fluid B. The cath will allow the doctor to better manage fluid therapy C. The cath tip comes to rest inside my brother pulmonary artery D. The cath will be in position until the heart has a change to heal
The catheter will allow the doctor to better manage fluid therapy
Following insertion of a central venous catheter, the nurse obtains a stat chest X-ray film to verify proper catheter placement. The radiologist reports to the nurse: "The tip of the catheter is located in the superior vena cava." What is the best interpretation of these results by the nurse? A. The catheter is not positioned correctly and should be removed B. The Cather position increase the risk fo ventricular dysrhythmias C. The distal tip of the catheter is in the appropriate position D. The physician should be called to advance the catheter into the pulmonary artery
The distal tip of the cath is in the appropriate position The tip of the central venous catheter should rest just above the right atrium in the superior vena cava, so the central venous catheter is positioned correctly in the superior vena cava.
