MCA 3: Clinical Skills Quizzes
To minimize the risk of air embolism, what instructions should the nurse give the patient before removing the PA catheter? A. "Take a deep breath and hold it." B. "Turn your head in the direction of the exit site." C. "Position yourself in the high-Fowler position." D. "Take slow deep breaths in and out." (Pulmonary Artery Catheter: Removal)
A. "Take a deep breath and hold it." (Rationale: Before removing a PA catheter, the nurse should instruct the patient to take a deep breath in and hold it. The patient's head may need to be turned away from the catheter exit site to gain access to the site. A high-Fowler position places the patient at risk for an air embolism. Taking slow deep breaths in and out places the patient at risk for an air embolism.)
What is a possible explanation when an abnormally low pressure reading displays on the monitor? A. Air in the system B. Line obstruction C. Interference from other infusions in the line D. Closed stopcock between the monitor and the patient. (Right Atrial and Central Venous Pressure Monitoring)
A. Air in the system (Rationale: An abnormally low reading may signal air in the system, broken tubing, or an open add-on device. An abnormally high reading may indicate a line obstruction or interference from other infusions in the line. Zeroing the transducer is a correct action to take in preparation for obtaining pressure readings. If a stopcock was closed between the monitor and the patient there would be no pressure reading as opposed to a low pressure reading.)
After a subclavian CVC is removed and hemostasis is achieved, what should the nurse do? A. Apply sterile petroleum-based ointment to the catheter exit site and cover it with a sterile dressing. B. Apply dry sterile gauze dressing to the catheter exit. C. Leave the catheter exit site open to air. D. Have the patient sit up in a chair for 30 minutes. (Central Venous Catheter: Removal)
A. Apply sterile petroleum-based ointment to the catheter exit site and cover it with a sterile dressing. (Rationale: After removing a CVC, the nurse should apply sterile petroleum-based ointment to the catheter exit site and cover it with a sterile dressing. The petroleum-based ointment helps seal the skin-to-vein tract and decrease the risk of air embolism. Using dry gauze or leaving off a dressing increases the risk of air embolism. The patient should remain flat or in a reclining position for 30 minutes after catheter removal. The patient should not sit up)
A CVC was just removed from a patient who is being discharged. Which information should be included in the patient's education plan? A. Call your provider if the site becomes red, swollen and warm to touch. B. Keep the dressing on until it falls off. C. Keep your arm in a sling for 24 hours to decrease using the arm. D. Apply an ice pack to the site every 4 hours for 4 minutes for a total of 24 hours. (Central Venous Catheter: Removal)
A. Call your provider if the site becomes red, swollen and warm to touch. (Rationale: The patient should be taught to monitor the catheter exit site for signs of infection or inflammation. The patient should also be instructed to change the site dressing daily and monitor the site for infection. The patient does not need to keep his or her arm in a sling nor apply ice packs to the site.)
The nurse suspects that a PA catheter is unintentionally in the wedge position. Which action should the nurse take first? A. Check the catheter to make sure the balloon is deflated. B. Contact the practitioner to reposition the catheter immediately. C. Fill the balloon in an attempt to move the tip out of the wedge position. D. Help the patient change position. (Pulmonary Artery Catheter: Troubleshooting)
A. Check the catheter to make sure the balloon is deflated. (Rationale: A balloon-tipped catheter can inadvertently move into the wedge position. If this occurs, the nurse should first check to make sure the balloon is deflated. If the balloon is deflated, the nurse should assist the patient with a position change because this may help the catheter move out of the wedge position. If the catheter remains wedged, the practitioner should be notified because the PA catheter needs to be immediately repositioned. The nurse may withdraw the PA catheter, according to the organization's practice. Filling an already inflated balloon can produce balloon rupture of the PA catheter or rupture of the patient's PA.)
Which action is a common cause of PA rupture? A. Keeping the balloon inflated for prolonged periods of time B. Passively deflating the balloon C. Inflating the balloon until the waveform changes to a PAOP D. Gentle inflation of the balloon (Pulmonary Artery Catheter: Troubleshooting)
A. Keeping the balloon inflated for prolonged periods of time (Rationale: Common causes of PA rupture are keeping the balloon inflated for prolonged periods of time and forceful over inflation of the balloon. The PA balloon should be inflated gently and for short periods to avoid prolonged pressure on the pulmonary arteriole. The balloon should be passively deflated by disconnecting the syringe from the balloon inflation port. The balloon should be gently inflated with only enough air to convert the PA waveform to a PAOP waveform.)
Continuous monitoring of the patient's CVP waveform reveals a marked change from 7 mm Hg to 1 mm Hg. After the nurse relevels the transducer, the reading is 2 mm Hg. Which intervention should be the next step? A. Notify the practitioner regarding the patient's status. B. Discontinue use of the monitoring system. C. Continue to observe the patient and recheck the CVP in 15 minutes. D. Relevel the transducer to the phlebostatic axis. (Right Atrial and Central Venous Pressure Monitoring)
A. Notify the practitioner regarding the patient's status. (Rationale: Abnormal CVP or RAP values or waveforms are reportable conditions. CVP and RAP indicate volume status. A reading of 2 mm Hg requires the nurse to assess the patient for hypovolemia. The decreased value requires immediate intervention; releveling the transducer again and continuing to observe the patient would delay necessary treatment. The monitoring system should stay in place.)
Which action should the nurse take to prepare for removal of a patient's PA catheter? A. Place the patient in a slight Trendelenburg position. B. Turn the patient's head in the direction of the PA catheter and introducer site. C. Place the patient in the high-Fowler position. D. Refrain from applying pressure as the introducer exits the site. (Pulmonary Artery Catheter: Removal)
A. Place the patient in a slight Trendelenburg position. (Rationale: Before removing a PA catheter, the patient should be placed in a slight Trendelenburg position. The patient's head should be turned away from the site. A high-Fowler position places the patient at risk for an air embolism. The nurse should apply pressure as the introducer exits the site to reduce the risk of a venous air embolus and promote hemostasis.)
While monitoring the patient's CVP or RAP, the nurse notices an abnormal waveform with increased measurements. What is the most likely cause of the change in the waveform and measurements? A. The catheter migrated into the right ventricle. B. The transducer was not leveled. C. The tubing is broken. D. The patient's heart failure is worse. (Right Atrial and Central Venous Pressure Monitoring)
A. The catheter migrated into the right ventricle. (Rationale: Waveforms that are abnormal with an increased range suggest that the catheter migrated into the right ventricle. A catheter that is not leveled would have a normal waveform but elevated or lower measurements. Tubing that is broken or cracked would cause a smaller than normal waveform. If the patient's heart failure is worse, his or her CVP or RAP measurement would be elevated with a normal waveform.)
While taking routine readings, the nurse observes that the patient's CVP is 17 mm Hg. Which condition is the most likely cause? A. Hypotension B. Heart failure C. Dehydration D. First-degree heart block (Right Atrial and Central Venous Pressure Monitoring)
B. Heart failure (Rationale: Normal CVP and RAP is 1 to 10 mm Hg. The CVP or RAP reading represents right-side heart preload or the volume of blood in the right ventricle at the end of diastole. With heart failure, increased preload and intravascular fluid volume cause increased CVP and RAP. With hypotension or dehydration, decreased preload causes decreased CVP and RAP. First-degree heart block has no effect on CVP and RAP.)
Which action best describes the correct procedure for removing a multilumen CVC? A. Ask the patient to take slow deep breaths. B. Remove the distal end quickly. C. Remove the distal end slowly. D. Remove the entire CVC slowly. (Central Venous Catheter: Removal)
B. Remove the distal end quickly. (Remove the distal end of a multilumen catheter quickly because the exposed proximal and medial openings could permit the entry of air.)
When preparing to remove the PA catheter, why does the nurse remove the syringe from the balloon inflation port of the catheter? A. Removing the syringe makes it easier to manipulate the catheter B. Removing the syringe ensures that the balloon is deflated C. Removing the syringe limits the risk of infection at the catheter exit site D. Removing the syringe limits the risk of air entry into the venous system (Pulmonary Artery Catheter: Removal)
B. Removing the syringe ensures that the balloon is deflated (Rationale: Removing the syringe ensures balloon deflation. Myocardial or valvular tissues can be damaged if the PA catheter is removed with the balloon inflated. Removing the syringe does not affect manipulation of the catheter, prevent an infection, or decrease the risk for air embolism.)
Before removing a subclavian CVC, the nurse should give the patient which instruction? A. Take a deep breath and exhale slowly. B. Take a deep breath and hold it. C. Inhale quickly when the catheter is being removed. D. Breathe normally during the removal process. (Central Venous Catheter: Removal)
B. Take a deep breath and hold it. (Rationale: When a patient has an internal jugular or a subclavian catheter, taking a deep breath and holding it prevents complications associated with air emboli. Breathing normally or inhaling, either quickly or slowly, does not maintain the ventilatory air pressure needed to avoid complications.)
While monitoring a patient the nurse notices that the PA waveform now looks like a PAOP waveform. The nurse suspects the tip of the catheter in now in the wedged position. Which finding would help confirm this suspicion? A. The external centimeter markings indicate the catheter moved from 53 cm to 45 cm. B. The external centimeter markings indicate the catheter moved from 53 cm to 57 cm. C. The PA catheter balloon is deflated and the balloon inflation port is locked. D. Flushing the catheter reveals a straight line and then ventricular dysrhythmias. (Pulmonary Artery Catheter: Troubleshooting)
B. The external centimeter markings indicate the catheter moved from 53 cm to 57 cm. (Rationale: In this situation the catheter has moved from 53 cm to 57 cm which is the most likely cause of this problem. The external centimeter marking of the PA catheter identifies the length of the PA catheter inserted and allows for evaluation of PA catheter movement. This comparison determines whether the catheter has moved from its previous location. If the catheter went from 53 cm to 45 cm the tip of the catheter would probably be in the RV not wedged in the PA. The deflated PA catheter balloon and locked balloon inflation port confirm the balloon is not inflated not that the catheter has moved. A wedged PA catheter should never be flushed.)
The nurse who is caring for a patient with a PA catheter notices that the PA waveform is a flat line. Which step should the nurse take first to troubleshoot the situation? A. Ask the patient to cough. B. Ask the patient to roll onto his or her side. C. Check for kinks in the tubing. D. Zero the transducer. (Pulmonary Artery Catheter: Troubleshooting)
C. Check for kinks in the tubing. (Rationale: Checking for kinks in the tubing is the first and easiest step before looking for other possible causes of a flat line or absent waveform. Asking the patient to cough and roll onto his or her side probably will not change the waveform if it is flat because of a disconnected or faulty cable. Zeroing the transducer may help, but it is not the first step in troubleshooting)
The patient cannot tolerate the Trendelenburg position for PA catheter removal. In which position should the nurse place the patient? A. High-Fowler position B. Right-lateral position C. Flat D. Left-lateral Trendelenburg position (Pulmonary Artery Catheter: Removal)
C. Flat (Rationale: The patient should be placed flat if the Trendelenburg position is contraindicated or if the patient cannot tolerate the Trendelenburg position. The patient should not be in the high-Fowler position; this would increase the risk of air embolism. The right-lateral position and the left-lateral Trendelenburg are not appropriate.)
The PA catheter was removed and the introducer remains in place to provide intravenous access. Which action should be taken next? A. Cover the introducer catheter with a sterile dressing. B. Connect the introducer to an IV infusion. C. Insert an obturator or cap into the introducer. D. Leave the introducer catheter open to air. (Pulmonary Artery Catheter: Removal)
C. Insert an obturator or cap into the introducer. (Rationale: The hemostasis valve of the introducer must be occluded to minimize the risk for an air embolus and hemorrhage. A sterile dressing should be used after the obturator or cap is applied. The introducer should be connected to IV fluids before the PA catheter is removed. The introducer catheter should not be left open to air because this action could promote the development of infection.)
The nurse is assisting the patient to a comfortable position in preparation for accurate measurement of central venous pressure. The patient is unable to lie supine. Into which alternate position can the nurse assist the patient? A. Lateral position with the head of the bed flat B. Prone position with the head of the bed raised C. Lateral position at 20, 30 or 90 degrees D. Lateral position at 10 degrees (Right Atrial and Central Venous Pressure Monitoring)
C. Lateral position at 20, 30 or 90 degrees (Rationale: If the patient cannot tolerate the supine position, the nurse should use the lateral position at 20, 30, or 90 degrees or the prone position with the head of the bed flat.)
A patient's CVP has increased from 12 mm Hg to 18 mm Hg. Which action should the nurse take next? A. Obtain a reading during inspiration. B. Place the patient in a 90-degree semirecumbent position. C. Level the air-fluid interface. D. Obtain three readings and average the results. (Right Atrial and Central Venous Pressure Monitoring)
C. Level the air-fluid interface. (Rationale: The air-fluid interface of the monitoring system should be leveled before a measurement is taken. The reading should be measured at end-expiration with the patient in the supine position and the head of the bed flat or elevated up to 60 degrees. Only one reading should be needed)
What action should the nurse take immediately after zeroing the transducer to atmospheric pressure? A. Perform the dynamic response test B. Level the transducer C. Open all stopcocks between the monitor and the patient D. Position the patient supine with the head of the between 0 and 60 degrees (Right Atrial and Central Venous Pressure Monitoring)
C. Open all stopcocks between the monitor and the patient (Rationale: After zeroing the transducer, all stopcocks between the monitor and the patient should be opened to allow for pressure readings. Positioning the patient supine with the head of the between 0 and 60 degrees and leveling the transducer should be performed before zeroing the transducer. Performing the dynamic response test should be performed after the stopcocks have been opened between the monitor and the patient.)
After the removal of a catheter, the nurse suspects that a venous air embolus is present. What is the most appropriate next step? A. Place the patient in a right-side lying Trendelenburg position. B. Place the patient in a supine position. C. Place the patient in a left lateral Trendelenburg position. D. Place the patient in a semi-Fowler position. (Central Venous Catheter: Removal)
C. Place the patient in a left lateral Trendelenburg position. (Rationale: If a venous air embolus is suspected, the patient should be positioned in a left lateral Trendelenburg position to prevent air from passing into the left side of the heart and traveling into the arterial circulation. Placing the patient in any other position may allow the air embolus to travel into the arterial circulation and cause a life-threatening complication.)
While assessing a patient who has a PA catheter, the nurse notices increased ventricular ectopy. Which waveform would the nurse most likely see when assessing the catheter waveform on the monitor? A. Overdamped waveform B. RA waveform C. RV waveform D. Arterial waveform (Pulmonary Artery Catheter: Troubleshooting)
C. RV waveform (Rationale: The PA catheter probably has slipped back into the right ventricle. The PA catheter tip may cause ventricular arrhythmias. If the PA balloon is inflated, the ventricular arrhythmias may decrease because the inflated balloon may cause less irritation of the endocardium. During inflation of the balloon, the PA catheter may also advance into the PA. The practitioner should be notified if the PA catheter needs to be advanced farther.)
Signs and symptoms of an air embolism after the PA catheter include which findings? A. Hypotension and abdominal pain. B. Respiratory distress and decreased urine output. C. Hypotension and liver pain. D. Cardiac arrhythmias and change in mental status. (Pulmonary Artery Catheter: Removal)
D. Cardiac arrhythmias and change in mental status. (Rationale: An air embolism can occur during or after PA catheter removal as a result of air being drawn in along the subcutaneous tract and into the vein. Signs and symptoms of an air embolism include respiratory distress, hypotension, cardiac arrhythmias, or a change in mental status. Abdominal pain, decreased urine output, and liver pain are not indicative of an air embolism.)
After obtaining a PAOP which is the correct way to deflate the balloon? A. Actively withdraw air from the balloon with the syringe quickly while attached to the balloon inflation port B. Actively withdraw air from the balloon with the syringe slowly while attached to the balloon inflation port C. Passively remove air from the balloon by letting the air go back in the syringe attached to the balloon inflation port D. Passively remove air from the balloon by disconnecting the syringe from the balloon inflation port (Pulmonary Artery Catheter: Troubleshooting)
D. Passively remove air from the balloon by disconnecting the syringe from the balloon inflation port (Rationale: The balloon should be deflated by disconnecting the syringe from the balloon inflation port and allowing the passive removal of air. Active withdrawal of air from the balloon either quickly or slowly should be avoided because it can weaken the balloon, pull the balloon structure into the inflation lumen, and possibly cause balloon rupture. Letting the air go back into the syringe is not passive deflation.)
When removing a patient's PA catheter, the nurse notices a rapid drop in the patient's blood pressure and heart rate accompanied by shortness of breath. Which is the most appropriate next step? A. Place the patient in a high-Fowler position. B. Place the patient in the right-lateral Trendelenburg position. C. Immediately administer atropine, 1 mg IV push. D. Place the patient in the left-lateral Trendelenburg position. (Pulmonary Artery Catheter: Removal)
D. Place the patient in the left-lateral Trendelenburg position. (Rationale: The nurse should immediately place the patient in the left-lateral Trendelenburg position and notify the practitioner because this patient has signs of a venous air embolus, which is a potentially life-threatening complication. The left-lateral Trendelenburg position prevents air from passing into the left side of the heart and traveling into the arterial circulation. The high-Fowler and the right-lateral Trendelenburg positions are not appropriate for this patient. Administering atropine is not indicated at this time.)
What important instruction should the nurse include when educating the patient and family about central lines? A. Inform the patient that movement while obtaining pressures will not affect the findings. B. Inform the patient that talking while obtaining pressures will not affect the findings. C. No specific instructions need to be provided when obtaining pressure readings. D. Provide information about prevention of central line-associated bloodstream infection. (Right Atrial and Central Venous Pressure Monitoring)
D. Provide information about prevention of central line-associated bloodstream infection. (Rationale: Educate the patient and family about preventing a CLABSI. The patient should be instructed to remain still and quiet during the procedure in order to obtain accurate results.)
After removing a CVC, which outcome should alert the nurse there may be a problem? A. Dressing clean dry and intact B. Patient has full range of motion in the arm C. The arm is warm and dry D. Signs of continued bleeding (Central Venous Catheter: Removal)
D. Signs of continued bleeding (Rationale: Signs of continued bleeding is an unexpected outcome and should alert the nurse there may be a problem. The dressing is clean dry and intact, the patient has full range of motion, and the arm is warm and dry are all normal and can be expected.)
A patient with a CVC has redness and drainage at the exit site. Which intervention is the most appropriate? A. Apply antibiotic ointment. B. Notify the practitioner. C. Remove the catheter. D. Insert another catheter in the same location. (Central Venous Catheter: Removal)
B. Notify the practitioner. (Rationale: CVCs are removed when therapy is completed, when the catheter's presence could cause complications (e.g., the catheter is malpositioned), or when the patient develops an infection. Redness and drainage at the catheter exit site are signs of infection, and the nurse's most appropriate intervention is to notify the practitioner. The practitioner orders the removal of the catheter and determines if a new catheter should be inserted. The nurse should not remove the catheter without collaborating with the practitioner. A catheter should not be reinserted into an infected site. Applying antibiotic ointment to an infected site is not appropriate; the catheter should be removed.)
In which position should the nurse place the patient when removing a catheter from the internal jugular or subclavian vein? A. Low Fowler position B. Reverse Trendelenburg position C. Supine in a slight Trendelenburg position D. High Fowler position (Central Venous Catheter: Removal)
C. Supine in a slight Trendelenburg position (Rationale: Positioning the patient supine in a slight Trendelenburg position or with the head of the bed flat when the Trendelenburg position is contraindicated minimizes the risk of venous air embolism. The lower the site of entry below the heart, the lower the pressure gradient; thus, the risk of venous air embolism is minimized. If the patient were in a Fowler position or the reverse Trendelenburg position, the site would be above the level of the heart.)
If air exists between the pressure bag and a stopcock, what should be the nurse's first priority? A. Rezero the hemodynamic monitoring system. B. Place a new sterile nonvented cap on the top port of the stopcock. C. Turn the stopcock off to the patient. D. Fast-flush the transducer system. (Pulmonary Artery Catheter: Troubleshooting)
C. Turn the stopcock off to the patient. (Rationale: Turning the stopcock off to the patient maintains the patient's safety. Fast-flushing the system without first turning off the stopcock to the patient could move the air in the line into the patient, causing a negative outcome. Rezeroing the system or placing a sterile nonvented cap is not the first priority; these actions should be taken after the air is removed)
What is the normal range for central venous and right atrial pressure? A. 1 to 10 mm Hg B. 10 to 20 mm Hg C. 1 to 20 mm Hg D. 20 to 30 mm Hg (Right Atrial and Central Venous Pressure Monitoring)
A. 1 to 10 mm Hg (*Bowman says 2-8 mm Hg*) (Rationale: Central venous pressure and right atrial pressure normally range from 1 to 10 mm Hg with a mean pressure of 5 mm Hg in healthy adults. All the other ranges provided at outside of this range.)
The nurse notices that the patient's PA waveform is overdamped. Upon inspection of the tubing, the nurse observes that there are no loose connections, the pressure bag is inflated to 100 mm Hg, and there are no air bubbles in the tubing. The patient is lying supine with the head of the bed slightly elevated. The transducer is leveled at the midaxillary line, and the stopcock is off to air and open to the patient and the transducer. What is a possible cause? A. The pressure bag is not fully inflated. B. The patient is lying supine with the head of the bed slightly elevated. C. The transducer is level at the midaxillary line. D. The stopcock is turned off to air and open to the patient and the transducer. (Pulmonary Artery Catheter: Troubleshooting)
A. The pressure bag is not fully inflated. (Rationale: The pressure infuser bag should be inflated to 300 mm Hg. Anything less may cause overdamping of the waveform. The patient should be supine with the head of the bed slightly elevated, the transducer should be leveled at the midaxillary line, and the stopcock should be turned off to air and open to the patient and the transducer.)
The nurse preceptor explains to a graduate nurse that in the cardiac cycle the a wave of the CVP or RAP waveform correlates with which physiologic process? A. Atrial relaxation B. Atrial contraction C. Ventricular contraction D. Tricuspid valve closure (Right Atrial and Central Venous Pressure Monitoring)
B. Atrial contraction (Rationale: The a wave reflects atrial contraction. Atrial contraction and the P-R interval correlate with the a wave on the CVP or RAP waveform. The c wave reflects bulging of the tricuspid valve into the atrium. The v wave reflects passive filling of the right atrium during ventricular contraction.)
While the nurse is removing a PA catheter, the patient goes into ventricular tachycardia. What is the nurse's most appropriate next step? A. Stop and call the practitioner. B. Continue to pull out the catheter. C. Advance and replace the catheter. D. Administer IV lidocaine and resume pulling. (Pulmonary Artery Catheter: Removal)
B. Continue to pull out the catheter. (Rationale: The nurse should continue to pull out the catheter. Ventricular tachycardia is possible when removing a PA catheter and is caused by mechanical irritation of the endocardium as the catheter passes through the right ventricle. The arrhythmia is usually self-terminating after removal of a PA catheter. Stopping midprocedure would worsen the situation. A catheter that is withdrawn should never be advanced because valve damage may occur. Once the catheter is removed, the ventricular tachycardia should stop. An antiarrhythmic agent, such as lidocaine, is not needed at this time.)
While discontinuing a CVC, the nurse meets resistance and the catheter appears stuck. What should be the nurse's next action? A. Ask another, more experienced nurse to try to remove the catheter. B. Switch hands and try to remove the catheter again. C. Stop the procedure and notify the practitioner. D. Have the patient take several deep breaths and cough. (Central Venous Catheter: Removal)
C. Stop the procedure and notify the practitioner. (Rationale: If resistance is met while discontinuing a CVC, the procedure should be stopped and the practitioner should be notified. The nurse should never pull the catheter because it may break or cause venous wall damage. Switching hands, trying again, and asking another nurse to try may only aggravate the situation. Having the patient take several deep breaths and cough may increase the risk of a venous air embolism, particularly while the catheter exit site is open (undressed).)
While discontinuing the PA catheter, the nurse meets resistance and the catheter appears stuck. What should be the nurse's next action? A. Ask another more experienced nurse to try to remove the catheter. B. Switch hands and try to remove the catheter again. C. Stop the procedure and notify the practitioner. D. Have the patient take several deep breaths and cough. (Pulmonary Artery Catheter: Removal)
C. Stop the procedure and notify the practitioner. (Rationale: If resistance is met while discontinuing a PA catheter, the procedure should be stopped and the practitioner should be notified. The nurse should never pull the catheter because it may break or cause venous wall damage. Switching hands, trying again, and asking another nurse to try may only aggravate the situation. Having the patient take several deep breaths and cough may increase the risk of a venous air embolism, particularly while the catheter exit site is open.)
When obtaining a PAOP, the nurse meets no resistance and observes that the PA waveform does not change to a PAO waveform. What action should the nurse take next? A. Actively deflate the balloon and try again to obtain wedge pressure according to the organization's practice. B. Continue to manipulate the balloon lumen to achieve a solid wedge waveform. C. Advance the PA catheter 1 to 2 cm until a wedge pressure is obtained. D. Discontinue balloon attempts and tape the inflation port closed. (Pulmonary Artery Catheter: Troubleshooting)
D. Discontinue balloon attempts and tape the inflation port closed. (Rationale: If no resistance is met during the PA catheter wedge attempt, balloon attempts should be discontinued, and the inflation port should be taped closed. Resistance should be felt when the PA balloon is inflated. The balloon may rupture because of overinflation, frequent inflations, or repeated aspiration of air from the balloon rather than allowing it to deflate passively. Advancing or manipulating the catheter will not correct the problem of a ruptured balloon.)
The nurse is removing a CVC from a patient being treated for glaucoma. Which instruction should the nurse give this patient? A. "Hold your breath but do not bear down." B. "Lie on your right side during the procedure." C. "Sit up when I remove the catheter." D. "Wear protective goggles during the procedure." (Central Venous Catheter: Removal)
A. "Hold your breath but do not bear down." (Rationale: A patient with glaucoma should avoid the Valsalva response and should not bear down during CVC removal; instead, the patient should be instructed to hold his or her breath to reduce the risk of venous air embolus. The patient should also be placed in the Trendelenburg position or the left lateral decubitus position (not the right side) and instructed not to move during the procedure. There is no need for the patient to wear protective goggles.
The nurse is removing an introducer from a patient being treated for glaucoma. Which instruction should the nurse give this patient? A. "Hold your breath but do not bear down." B. "Lie on your right side during the procedure." C. "Sit up when I remove the catheter." D. "Wear protective goggles during the procedure." (Pulmonary Artery Catheter: Removal)
A. "Hold your breath but do not bear down." (Rationale: A patient with glaucoma should avoid the Valsalva response and should not bear down during catheter removal; instead, the patient should be instructed to hold his or her breath to reduce the risk of venous air embolus. The patient should also be placed in the Trendelenburg position or the left-lateral decubitus position (not the right side) and instructed not to move during the procedure. There is no need for the patient to wear protective goggles.)
Which complication can occur from an overwedged balloon? A. Dizziness and lightheadedness B. Bradycardia C. PA rupture D. Decrease in blood pressure (Pulmonary Artery Catheter: Troubleshooting)
C. PA rupture (Rationale: Overwedging a balloon may cause the PA to rupture. Dizziness and lightheadedness, bradycardia, and a decrease in blood pressure are not associated with an overwedged balloon.)
