WOC: Exam 1-HD
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 mm Hg C. A hypovolemic patient with a central venous pressure (CVP) of 6 mm Hg D. A patient with a pulmonary artery occlusion pressure (PAOP) of 10 mm Hg
ANS: A A cardiac output of 2.0 L/min in a patient with cardiogenic shock warrants immediate assessment. A PAP of 20 mm Hg, CVP of 6 mm Hg, and a PAOP of 10 mm Hg are all within normal limits.
The nurse is caring for a 70-kg patient 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
ANS: A An arterial lactate level of 1.0 mEq/L is within normal limits and is indicative of normal oxygen delivery to the tissues. The cardiac output, mixed venous saturation, and cardiac index values are all below normal limits indicating inadequate cardiac output sufficient to provide oxygen delivery to the organs and tissues.
A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respira- tions 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vascular resistance of 3000 -5 dynes/sec/cm, and a hematocrit of 20%. The nurse anticipates administration of which the following therapies or medications? A. Blood transfusion B. Furosemide (Lasix) C. Dobutamine (Dobutrex) infusion D. Dopamine hydrochloride (Dopamine) infusion
ANS: A Both hemodynamic parameters and the reported hematocrit value indicate hypovolemia and blood loss requiring volume resuscitation with blood products. Furosemide administration will worsen fluid volume status. Inotropic agents will not correct the underlying fluid volume deficit and anemia. Vasoconstrictors are contraindicated in a volume-depleted state.
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
ANS: A Diminished breaths sounds over the lung field on the same side of the line insertion site may be indicative of a pneumothorax. A pneumothorax, which can develop slowly, is a major complication following insertion of central lines when the subclavian route is used. Localized pain at catheter insertion site is not the immediate priority in this scenario. A measured central venous pressure of 5 mm Hg is normal. Slight bloody drainage at the insertion site soon after the procedure does not require immediate action.
The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best reduces the risk of catheter- related bloodstream infection (CRBSI)? A. Review daily the 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.
ANS: A Duration of the catheter is an independent risk factor for CRBSI, and removal of the catheter when not needed to guide treatment is associated with a reduction in mortality. Maintaining of the insertion site should be guided by institutional guidelines and is best accomplished with chlorhexidine skin antisepsis. Minimizing the number of times the flush system is opened by changing tubing no more frequently than every 72 to 96 hours reduces the risk of CRBSI. Maintaining a pressure of 300 mm Hg on the flush solution bag helps maintain the integrity of the invasive line and does not reduce the risk of infection.
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.
ANS: A To maintain the patency of the arterial line, the inflation volume of the flush system pressure bag should be inflated to 300 mm Hg to ensure a constant flow of fluid through the system, preventing backward flow of blood into the system tubing. Disconnecting the flush system from the arterial line is not appropriate and could increase the risk of infection to the patient. Zero referencing the system will not help clear the blood from the system tubing. Reducing the number of stopcocks helps reduce the risk of a disconnection that could lead to excessive blood loss.
The nurse is caring for a 100-kg patient being monitored with a pulmonary artery catheter. The nurse assesses a blood pressure of 90/60 mm Hg, heart rate 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. 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
ANS: A A cardiac index of 1.2 L/min/m3 combined with the identified clinical assessment findings indicate a low cardiac output with fluid overload (bilateral crackles) requiring intervention. The remaining hemodynamic values are within normal limits: cardiac output of 4 L/min; pulmonary vascular resistance of 80 dynes/sec/cm-5; and the systemic vascular resistance of -5
Which nursing actions are most important for a patient with a right radial arterial line? (Select all that apply.) A. Checking the 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
ANS: A, B, C Options A, B, and C are required to ensure proper functioning of the arterial line.There is no need to restrain all extremities. Depending on the patient's level of sedation, the right hand may need gentle restraint.
The nurse is preparing for insertion of a pulmonary artery catheter (PAC). During insertion of the catheter, what are the priority nursing actions? (Select all that apply.) A. Allay the patient's anxiety by providing information 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 physician. D. Monitor the patient's cardiac rhythm throughout the entire procedure. E. Obtain informed consent by informing the patient of procedural risks.
ANS: A, B, C, D During insertion of a pulmonary artery catheter (PAC/Swan-Ganz), the nurse should allay the patient's anxiety, ensure that the sterile field is maintained to decrease the risk of infection, inflate the balloon upon request of the physician to assist in catheter placement, and monitor for dysrhythmias that may occur as the catheter passes through the right ventricle. Informed consent may be witnessed by the nurse, but it is obtained by the physician and should occur before the procedure begins.
When performing an initial pulmonary artery occlusion pressure (PAOP), what are the best nursing actions? (Select all that apply.) 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 for 8 hours following insertion. D. Zero reference and level the air-fluid interface of the transducer at the level of the phlebostatic axis.
ANS: A, B, D To obtain an accurate pulmonary artery occlusion pressure (PAOP), the transducer system should be zero referenced and leveled to ensure accurate readings, and the balloon should be inflated with enough air, for no more than 8 to 10 seconds until a change in waveform is noted. The volume of air necessary to inflate the balloon should be documented. Maintaining the balloon in the inflated position can lead to pulmonary infarction.
The nurse is preparing to obtain a right atrial pressure (RAP/CVP) reading. What are the most appropriate nursing actions? (Select all that apply.) A. Compare measured pressures with other physiological parameters. B. Flush the central venous catheter with 20 mL of sterile saline. C. Inflate the balloon with 3 mL 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.
ANS: A, D, E To obtain an accurate right atrial pressure (RAP/CVP) reading, the transducer system should be zero referenced and leveled with the phlebostatic axis to ensure accurate readings; the value should be obtained during end exhalation, and any obtained measure should be evaluated in light of the patient's physiological parameters and physical assessment. The catheter does not need to be flushed before measurement because continuous saline flush is part of the RAP system. There is no balloon with a right atrial pressure (RAP/CVP) catheter.
The nurse is educating a patient's 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 catheter will provide multiple sites to give intravenous fluid." B. "The catheter will allow the physician to better manage fluid therapy." C. "The catheter tip comes to rest inside my brother's pulmonary artery." D. "The catheter will be in position until the heart has a chance to heal."
ANS: B A pulmonary artery catheter provides hemodynamic measurements that guide interventions that include appropriate fluid therapy. Even though a pulmonary catheter provides multiple intravenous access sites, this is not the primary purpose of the catheter. Although the catheter is positioned in the pulmonary artery, positioning is not the purpose of the catheter. The primary purpose of the catheter is not to aid in the healing of the heart but to guide therapy.
The nurse is preparing to measure the thermodilution cardiac output (TdCO) in a patient being monitored with a pulmonary artery catheter. 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 mm Hg on the flush solution using a pressure bag. D. Limit the length of the noncompliant pressure tubing to a maximum 48 inches.
ANS: B Avoiding infusing vasoactive agents into the port used to obtain the thermodilution cardiac output (TdCO) measurement prevents the patient from receiving a bolus of these agents during rapid infusion of the injectate solution. Ensuring zero referencing of the transducer, maintaining 300 mm Hg pressure of the system pressure bag, and limiting the length of the pressure tubing help to ensure the obtained measures are accurate and do not influence safety.
The nurse is caring for a patient 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
ANS: B Numbness and tingling in the left hand, which is the location of an arterial catheter, indicates possible neurovascular compromise and requires immediate action. A dampened waveform can indicate problems with arterial line patency but is not an emergent situation. Slight bloody drainage at the subclavian insertion site is not an unusual finding. Slight redness at the insertion site, while of concern, does not require immediate action.
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 mm Hg decrease in arterial blood pressure. What is the best interpretation of this finding by the nurse? A. The mechanical ventilator 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.
ANS: B The increase in thoracic pressure that occurs during the inspiration phase of positive pressure ventilation decreases venous return, decreasing systolic blood pressure.A systolic blood pressure variation or decrease of more than 10 mm Hg in a mechanically ventilated patient is indicative of a patient who would respond to fluid resuscitation and improve tissue perfusion. There is no evidence to indicate the ventilator is malfunctioning, the arterial line needs to be replaced, or that the left limb may have reduced perfusion.
The nurse returns from the cardiac catheterization laboratory 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 catheter balloon with 1 mL air. D. Inject 10 mL of 0.9% normal saline into the proximal port.
ANS: B To ensure accurate measurement, zero referencing of the transducer system is a priority action after moving a patient and should be completed prior to injecting 10 mL of room temperature 0.9% normal saline. A pulmonary artery catheter occlusion pressure should be documented before obtaining a cardiac output, but without zero referencing the system following move- ment of a patient, the obtained value may be inaccurate. Inflating the pulmonary artery catheter balloon with 1 mL of air, while appropriate, is not a step required prior to obtaining a cardiac output.
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 catheter using a 0.9% normal saline solution pressurized at 300 mm Hg D. Using noncompliant pressure tubing that is no longer than 36 to 48 inches and has minimal stopcocks
ANS: B To ensure that an accurate SvO2 is obtained, calibration of the invasive monitoring system (e.g., PAC) is accomplished upon insertion and requires both a central venous blood sample from the PAC and an arterial blood gas sample. This process is unique to the accuracy of venous oxygen saturation monitoring systems. Zero referencing the transducer at the level of the phlebostatic axis, ensuring patency of the catheter with a pressurized flush system, and using tubing of adequate length ensure accuracy of all hemodynamic monitoring systems.
The physician writes an order to discontinue a patient's left radial arterial line. When discontinuing the patient's 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 patient's wrist in a neutral position.
ANS: B Upon removal of an invasive arterial line, adequate pressure must be applied for at least 5 minutes to ensure adequate hemostasis. Application of an air occlusion dressing is not standard of care following removal of an arterial line. Elevation of the affected limb following removal of an arterial line is not a necessary intervention. Neutral wrist position is optimum while the catheter is in place and not necessary after catheter discontinuation.
The nursing is caring for a patient 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.
ANS: B Loose connections in hemodynamic monitoring tubing can lead to hemorrhage, a major complication of arterial pressure monitoring. Application of a pressure dressing is required only upon arterial line removal. Blood return is adequate confirmation of arterial line placement; x-ray studies are not performed to confirm arterial line placement. Neutral positioning of the extremity and use of an arm board, without limb restraint, is the standard of care.
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
ANS: B Low pulmonary artery occlusion pressures usually indicate volume depletion, so intravenous fluids would be indicated. Administration of diuretics would worsen the patient's volume status. Negative inotropes would not improve the patient's volume status. Vasopressors will increase blood pressure but are contraindicated in a low volume state.
Which of the following situations may result in a low cardiac output and low cardiac index? (Select all that apply.) A. Exercise B. Hypovolemia C. Myocardial infarction D. Shock
ANS: B, C, D Hypovolemia, myocardial infarction, and shock often result in a decreased cardiac output. Cardiac output is usually increased with exercise.
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. A patient with a central venous pressure (RAP/CVP) of 6 mm Hg and 40 mL of urine output in the past hour B. A patient with a left radial arterial line with a BP of 110/60 mm Hg and slightly dampened arterial waveform C. A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula D. A patient with a pulmonary artery pressure of 25/10 mm Hg and an oxygen saturation of 94% on 2 L of oxygen via nasal cannula
ANS: C A high pulmonary artery occlusion pressure of 25 mm Hg combined with low oxygen saturation is indicative of fluid volume overload and warrants priority action because the patient is at risk for hypoxemia. A CVP of 6 mm Hg with 40 mL of hourly urine output are Acceptable assessment findings. A patient with a normal blood pressure and with a slightly dampened waveform does not require immediate action. A pulmonary artery pressure of 25/10 mmHg and a normal oxygen saturation does not require immediate treatment.
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 xray. 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 xray.
ANS: C After obtaining a pulmonary artery occlusive pressure and deflating the balloon, the monitor tracing indicates the waveform has returned to a normal pulmonary artery waveform. The nurse should document the occlusive value and continue monitoring the patient. Turning the patient to the left side, zero-referencing the system and performing a dynamic response test are not necessary as the waveform displayed is normal.
While inflating the balloon of a pulmonary artery catheter (PAC) with 1.0 mL of air to obtain a pulmonary artery occlusion pressure (PAOP), the nurse encounters resistance. What is the best nursing action? A. Add an additional 0.5 mL of air to the balloon and repeat the procedure. B. Advance the catheter with the balloon deflated and repeat the procedure. 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.
ANS: C Balloon inflation should never be forced because the PAC may have migrated further into the pulmonary artery, creating resistance to balloon inflation. Verification of proper line place- ment is warranted to avoid pulmonary artery rupture. In addition, the PAC waveform should be observed to assist in identifying location of the tip of the PAC. In this scenario, adding additional air to the balloon will further risk pulmonary artery rupture.Advancing a pulmonary artery catheter is not within the nurse's scope of practice.Flushing the distal port with saline may be indicated to ensure patency; however, the balloon of the PAC should never be locked in the inflated position as rupture of the pulmonary artery may occur.
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 hemodynamic values. C. Level and zero reference the air-fluid interface of the transducer with the patient's head of bed elevated to 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.
ANS: C Elevation of the head of bed is an important intervention to prevent aspiration and ventilator- associated pneumonia. Patients who require hemodynamic monitoring while receiving tube feedings should have the air-fluid interface of the transducer leveled with the phlebostatic axis while the head of bed is elevated to at least 30 degrees. Readings will be accurate. Supine positioning of a mechanically ventilated patient increases the risk of aspiration and ventilator- associated pneumonia and is contraindicated in this patient. Hemodynamic values can be accurately measured and trended in with the head of the bed elevated as high as 60 degrees. Even though hemodynamic values can be obtained in lateral positions, it is technically difficult and not accurate unless the positioning of the transducer is exact. Regardless, head of bed elevation is indicated for this patient.
After pulmonary artery catheter insertion, the nurse assesses a pulmonary artery pressure of 45/25 mm Hg, a pulmonary artery occlusion pressure (PAOP) of 20 mm Hg, 2.6 cardiac output of 2.6 L/min and a cardiac index of 1.9 L/min/m . Which physician order is of the highest priority? Apply 50% oxygen via venture mask. Insert an indwelling urinary catheter. Begin a dobutamine (Dobutrex) infusion. Obtain stat cardiac enzymes and troponin.
ANS: C The pulmonary pressures are higher than normal, indicating elevated preload, and the cardiac index and output values are low. The priority order for the nurse to implement is to begin a dobutamine (Dobutrex) infusion to improve cardiac output, possibly reducing pulmonary artery occlusion pressures. The other treatments are important, but the dobutamine infusion is the most important at this time.
The nurse is caring for a patient with an arterial monitoring system. The nurse assesses the patient's noninvasive cuff blood pressure to be 70/40 mm Hg. The arterial blood pressure measurement via an intraarterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. 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.
ANS: C Under normal circumstances, a difference of 10 to 20 mm Hg or more between invasive and noninvasive blood pressure is expected, with the invasive value being higher than the noninvasive value. The cuff used for noninvasive measurement should be assessed for proper cuff size. Given that the invasive value is substantially higher, before initiating corrective actions based on a single noninvasive measurement, such as activating the rapid response system, placing the patient in Trendelenburg position, or administering a fluid bolus, further assessment and troubleshooting are necessary.
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 catheter position increases the risk of 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.
ANS: C X-ray results indicate proper position of the catheter. The tip of the central venous catheter should rest just above the right atrium in the superior vena cava. The central venous catheter is positioned correctly in the superior vena cava. Dysrhythmias occur if the catheter migrates to the right ventricle. Central venous catheters are placed into great vessels of the venous system and not advanced into the pulmonary artery.
The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 125 beats/min, respiratory rate 35 breaths/min, and 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 physician's order? a. Titrate supplemental oxygen to achieve a SpO2 > 94%. b. Infuse 500 mL 0.9% normal saline over 1 hour. c. Obtain arterial blood gas and serum electrolytes. d. Administer furosemide (Lasix) 20 mg intravenously.
ANS: D A central venous pressure of 1 mm Hg, pulmonary artery occlusion pressure of 1 mm Hg along with a blood pressure of 85/40 mm Hg and heart rate of 125 are indicative of a low volume state. Infusion of 500 mL of 0.9% normal saline will increase circulating fluid volume. Administration of furosemide (Lasix) is contraindicated and could further reduce circulating fluid volume. Titrating supplemental oxygen, obtaining serum blood gas and electrolyte samples, although not a priority, are appropriate interventions.
While caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary artery occlusion pressure (PAOP) to be significantly higher than previously recorded values. The nurse assesses respirations to be unlabored at 16 breaths/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally. What is the priority nursing action? A. Increase supplemental oxygen and notify respiratory therapy. B. Notify the physician immediately of the assessment findings. C. Obtain a stat chest x-ray film to verify proper catheter placement. D. Zero reference and level the catheter at the phlebostatic axis.
ANS: D A hemodynamic value not supported by clinical assessment should be treated as questionable. To ensure the accuracy of hemodynamic readings, the catheter transducer system must be leveled at the phlebostatic axis and zero referenced. In this example, the catheter transducer system may be lower than the phlebostatic axis, resulting in erroneously higher pressures. Clinical manifestations do not support increasing supplemental oxygen. Clinical manifesta- tions do not warrant physician intervention; aberrant values should be investigated further. An aberrant value warrants further investigation, which includes zero referencing and checking the level as an initial measure. A chest x-ray study is not warranted at this time.
During insertion of a pulmonary artery catheter, the physician asks the nurse to assist by inflating the balloon with 1.5 mL of air. As the physician advances the catheter, 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 catheter. 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.
ANS: D During the insertion of the pulmonary artery catheter, ventricular dysrhythmias may occur as the catheter passes through the right ventricle. Treatment with lidocaine hydrochloride may be necessary to suppress the irritated ventricle and should be readily available. Withdrawing of the catheter is not within the scope of practice of the nurse and may not be necessary. Having the patient cough and deep-breathe will not correct the problem. The maximum volume of air necessary to inflate the balloon is 1.5 mL. Any additional volumes added may increase the risk of complications.
The nurse is caring for a patient with an admitting diagnosis of congestive 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 patient's supine position to no more than 10 seconds. B. Administer anxiety medications while recording the pressure. C. Encourage the patient to take slow deep breaths while supine. D. Elevate the head of the bed 45 degrees while recording pressures.
ANS: D Hemodynamic parameters can be accurately measured and trended with the head of the bed elevated to 45 degrees as long as the zeroing stopcock is properly leveled to the phlebostatic axis. Elevating the head of the bed to 45 degrees would be the optimum position to obtain a pulmonary artery occlusion pressure for a patient that becomes anxious and tachypneic when flat. Administering anxiety medications is not standard of care for obtaining hemodynamic pressures. Encouraging slow deep breaths while supine may inappropriately alter hemody- namic readings by altering intrathoracic pressure.
The nurse is preparing to obtain a pulmonary artery occlusion pressure (PAOP) reading for a patient 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 head of bed elevated 30 degrees and document the average PAOP pressure obtained. D. Place the patient with the head of bed elevated 30 degrees and record the PAOP just before the increase in pressures during inhalation.
ANS: D Pressures are highest when measured at end exhalation in the spontaneously breathing patient. In mechanically ventilated patients, 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. The head of bed should be elevated to 30 degrees. Pulmonary artery occlusion pressure is not averaged, but measured during inhalation in the mechanically ventilated patient while appropriate position- ing is maintained.
The charge nurse has a Vigileo pulse contour cardiac output monitoring system available for use in the surgical intensive care unit. For which patient is use of this device most appropriate? A. A patient with a history of aortic insufficiency admitted with a postoperative myocardial infarction B. A mechanically ventilated patient with cardiogenic shock being treated with an intraaortic balloon pump C. A patient with a history of atrial fibrillation having frequent episodes of paroxysmal supraventricular tachycardia D. A mechanically ventilated patient admitted following repair of an acute bowel obstruction
ANS: D Pulse contour analysis systems provide stroke volume variation and pulse pressure variation data and are better predictors of fluid responsiveness in mechanically ventilated patients. A patient postoperative from repair of an acute bowel obstruction that is mechanically ventilated is an appropriate candidate for this method of monitoring.Aortic insufficiency, intraaortic balloon pump therapy, and the presence of cardiac dysrhyth- mias are conditions in which pulse contour analysis systems are either inaccurate or contraindicated.
The nurse is caring for a patient 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.
ANS: D When hemodynamic monitoring is being done, it is important to set alarm limits to alert the nurse to changes in the patient's condition. Hemodyanamic values and waveforms are recorded at scheduled intervals and it is important that the tubing not be too long; however, alarm alerts are of highest priority. The lines are zero referenced per hospital policy, more frequently than daily.
After assessing a patient's hemodynamic parameters the nurse determines that preload and afterload are both elevated. These findings are consistent with which health problems? Standard Text: Select all that apply. 1. Pericardial tamponade 2. Constrictive pericarditis 3. Hypovolemia 4. Neurogenic shock 5. Mitral stenosis
Correct Answer: 1,2 Rationale 1: Both right and left preload are elevated in conditions that cause increases in pericardial pressures such as pericardial tamponade. Rationale 2: Both right and left preload are elevated in conditions that cause increases in pericardial pressures such as constrictive pericarditis.
The nurse is concerned that a patient's pulmonary artery has slipped into the right ventricle. What are the hallmarks of the waveform that the nurse observes on the monitor? Standard Text: Select all that apply. 1. Low diastolic pressure 2. No dicrotic notch 3. Continuous wedge waveform 4. Sharp upstroke, a plateau, and a rapid downstroke extending below the baseline 5. Smooth upstroke followed by a gradual downslope to the baseline
Correct Answer: 1,2 Rationale 1: One hallmark of right ventricular pressure is low diastolic pressure. Rationale 2: One hallmark of right ventricular pressure is a lack of dicrotic notch. Rationale 3: A continuous wedge waveform indicates the catheter is wedged in a pulmonary vessel. Rationale 4: This describes the waveform caused by the square wave test. Rationale 5: This describes a cardiac output curve.
The nurse wants to assess the oxygenation status of a patient who has been experiencing a gastrointestinal bleed. How will the nurse complete this assessment? Standard Text: Select all that apply. 1. Use pulse oximetry 2. Send a blood sample for arterial blood gas analysis 3. Auscultate lung sounds 4. Evaluate cardiac rhythm strip 5. Calculate mean arterial pressure
Correct Answer: 1,2 Rationale 1: At the bedside the arterial oxygen saturation can be estimated by pulse oximetry. Rationale 2: At the bedside the arterial oxygen saturation can be measured via an arterial blood gas analysis.
While caring for a patient in the intensive care unit, when would the nurse plan to conduct the square wave test on the patient's arterial pressure monitoring system? Standard Text: Select all that apply. 1. At the beginning of the shift 2. After drawing blood 3. When the arterial tracing is not consistent with an auscultated blood pressure 4. When the monitoring cable is disconnected from the flush system 5. Any time the patient's position is changed
Correct Answer: 1,2,3 Rationale 1: The square wave test should be performed during every shift. Rationale 2: The square wave test should be performed after opening the system, such as when drawing blood. Rationale 3: The square wave test should be performed when values are suspected to be inaccurate. Rationale 4: Zeroing should be done when the monitoring cable is disconnected from the flush system. Rationale 5: Releveling is to be done any time the patient's position is changed.
A patient has a central line for fluid management and antibiotic therapy. What interventions will the nurse utilize to reduce the risk of infection in the access site? Standard Text: Select all that apply. 1. Practice thorough hand hygiene. 2. Use chlorhexidine skin asepsis. 3. Review the continued need for the line daily. 4. Cover the insertion site with an opaque gauze dressing. 5. Change the dressing over the insertion site using clean technique.
Correct Answer: 1,2,3 Rationale 1: This is a best practice within the central line bundle to prevent central line infections. Rationale 2: This is a best practice within the central line bundle to prevent central line infections. Rationale 3: This is a best practice within the central line bundle to prevent central line infections. Rationale 4: This approach would restrict the nurse's ability to observe the insertion site for infection and should not be done. Rationale 5: Central line dressings should be changed using sterile technique to reduce the risk of infection.
The nurse is planning to assess the blood pressure of a patient with a BMI of 40. Which approaches will the nurse use to correctly obtain this patient's blood pressure? Standard Text: Select all that apply. 1. Use a cuff with a bladder that is 80% of the patient's arm circumference. 2. Use a thigh cuff. 3. Use an adult cuff on the patient's forearm. 4. Assess the blood pressure using the same approach each time. 5. Use an adult cuff on the patient's thigh.
Correct Answer: 1,2,3,4 Rationale 1: A cuff with a bladder that is 80% of the patient's arm circumference should be chosen. Rationale 2: A thigh cuff can be used. Rationale 3: An adult cuff may be used on the patient's forearm. Rationale 4: The blood pressure should be taken in the same way each time. Rationale 5: This is not a recommended approach to obtain the blood pressure on an obese patient.
The health care provider is planning to insert a pulmonary artery catheter into a patient. The nurse realizes this monitoring device is used to: Standard Text: Select all that apply. 1. Determine hemodynamic stability in heart failure 2. Monitor the effects of vasodilator administration 3. Monitor cardiac function during vascular surgical procedures 4. Assess cardiac output 5. Continuously monitor blood pressure
Correct Answer: 1,2,3,4 Rationale 1: A pulmonary artery is used to determine hemodynamic stability in cardiac disorders such as heart failure. Rationale 2: The pulmonary artery catheter is used to guide medication effects such as vasodilators. Rationale 3: The pulmonary artery catheter is used to monitor cardiac function during vascular procedures such as abdominal aneurysm repair. Rationale 4: The pulmonary artery catheter is used to assess cardiac output. Rationale 5: The pulmonary artery catheter is not used to continuously monitor blood pressure.
The nurse is concerned that the hand with an arterial line in the wrist is becoming ischemic. What did the nurse assess in this patient? Standard Text: Select all that apply. 1. Delayed capillary refill 2. Pale skin color of the wrist and hand 3. Reduced pulses in the brachial artery 4. Hand cold to touch 5. Blood pressure discrepancy of 15 mm Hg
Correct Answer: 1,2,4 Rationale 1: Evidence of tissue ischemia in the cannulated extremity includes delayed capillary refill. Rationale 2: Evidence of tissue ischemia in the cannulated extremity includes pallor. Rationale 3: Evidence of tissue ischemia in the cannulated extremity includes a reduction in pulses distal to the cannula. Rationale 4: Evidence of tissue ischemia in the cannulated extremity includes cool temperature. Rationale 5: This is not evidence of tissue ischemia in the cannulated extremity.
A patient is experiencing reduced afterload. The nurse realizes that causes of reduced afterload include: Standard Text: Select all that apply. 1. Sepsis 2. Mitral stenosis 3. Reduced circulating blood volume 4. Vasodilator medications 5. Myocarditis
Correct Answer: 1,4 Rationale 1: Sepsis causes vasodilation due to the release of endotoxins. Rationale 2: Mitral stenosis causes increased preload. Rationale 3: Reduced circulating blood volume contributes to decreased preload. Rationale 4: Vasodilators enlarge the vessels and reduce resistance. Rationale 5: Myocarditis contributes to elevated preload.
A patient with a PA catheter has an SVO2 of 90%. The nurse should assess the patient for: 1. Fever 2. Pain 3. Hypothermia 4. Anemia
Correct Answer: 3 Rationale 1: Fever causes a drop in the SVO2. Rationale 2: Pain causes a drop in the SVO2. Rationale 3: Normal SVO2 is 60% to 75%. This is a high SVO2, which means that there is not enough extraction of O2 from the hemoglobin to the tissues. This can occur with hypothermia. Rationale 4: Anemia causes a drop in the SVO2.
The nurse is monitoring the PA pressure of a mechanically ventilated patient. In order to accurately measure this pressure, the nurse should obtain the measurement: 1. Whenever because the timing does not matter 2. At the last clear waveform before the baseline drops 3. At the last clear waveform before the baseline rises 4. With the patient off the ventilator
Correct Answer: 3 Rationale 1: Timing does matter because the measurement can be elevated because of the ventilator. Timing is crucial for accuracy. Rationale 2: If it is measured before the baseline drops, this reading is high as the result of increased thoracic pressure in the chest from the positive pressure given by the ventilator. Rationale 3: The positive pressure of the ventilator causes an abnormally high reading during inspiration. The accurate measurement is the reading seen before the baseline rises. Rationale 4: Taking the patient off the ventilator is not an option.
The nurse suspects that a patient is experiencing cardiogenic shock. Which parameter indicates that the nurse's suspicion is correct? 1. Cardiac output of 8.9 L/min 2. Pulmonary artery wedge pressure (PAWP) of 8 mm Hg 3. Central venous pressure (CVP) of 5 mm Hg 4. Cardiac index (CI) of 1.8 L/min/m2
Correct Answer: 4 Rationale 1: This cardiac output is elevated and is not consistent with cardiogenic shock. Rationale 2: The PAWP will be elevated in cardiogenic shock. Rationale 3: This is a normal central venous pressure reading. Rationale 4: The cardiac index (CI) is a measure of cardiac output and tissue perfusion in relation to the patient's body surface area. This reading would be consistent with cardiogenic shock.
A patient has mixed venous oxygen saturation (SVO2) of 52% with the following hemodynamic findings: CO of 4.8 L/min, SaO2 of 95%, and an unchanged hemoglobin level. The nurse should assess the patient for: 1. Excessive sedation 2. Position of the PA catheter 3. Hypothermia 4. Pain
Correct Answer: 4 Rationale 1: Excessive sedation contributes to a higher than normal SVO2 level due to a lower level of oxygen extracted by the tissues. Rationale 2: This would not influence the patient's blood levels of oxygen and carbon dioxide. Rationale 3: Hypothermia contributes to a higher than normal SVO2 level due to a lower level of oxygen extracted by the tissues. Rationale 4: Pain causes an increased consumption of oxygen; therefore, the SVO2 level will decrease.
A patient with a right subclavian triple lumen catheter has a CVP reading of 18 mm Hg. The nurse would further assess the patient for symptoms of: 1. Peripheral edema and jugular vein distention 2. Decreased peripheral pulses and cool extremities 3. Hypovolemia and hypotension 4. Orbital edema and disorientation
Rationale 1: An elevated CVP indicates hypervolemia and/or right ventricular failure because it is a direct measurement of pressure in the right side of the heart. This is manifested by jugular vein distention and peripheral edema.
The health care provider is preparing to insert a PA catheter. The nurse should ensure that: 1. The patient is in the Trendelenburg position to prevent air embolism. 2. The patient has received a dose of IV lidocaine. 3. The site has been cleaned with soap and water. 4. A tourniquet has been applied to the neck.
Rationale 1: The Trendelenburg position promotes venous filling in the upper body for easier catheter insertion and prevention of air embolism.
Which nursing intervention ensures an accurate cardiac output reading for a patient? 1. Administer the injectate within 4 seconds. 2. Use 5 cc of iced saline as the injectate. 3. Ensure that there is a difference of 10°C between the injectate temperature and the patient's body temperature. 4. Inject the fluid into the pulmonary artery distal port.
Rationale 1: This time frame is necessary to ensure accuracy because the injectate will be pumped out during one cardiac cycle.
Before determining a patient's cardiac output, the nurse reviews normal values and realizes the value for cardiac output is: 1. 6-9 L/min 2. 4-8 L/min 3. 8-10 L/min 4. 2-4 L/min
Rationale 2: The heart pumps the entire blood volume through the body in 1 minute. This is the normal cardiac output.
A patient has a blood pressure of 134/70 per blood pressure cuff and a blood pressure of 90/50 per arterial line. The nurse should: 1. Discontinue the arterial line immediately. 2. Check the level of the transducer and relevel and rezero the system. 3. Do nothing because this is a normal variation between the two methods of measurement. 4. Begin the infusion of a dopamine drip.
Rationale 2: The placement of the transducer is essential for accurate measurement. It must be level with the phlebostatic axis in order for the monitoring system to be accurate.
The nurse is monitoring a patient's pulmonary vascular resistance. Which value is the normal value? 1. 100-250 mm Hg 2. 10-250 dynes/sec/cm2 3. 400-800 mm Hg 4. 800-1,400 dynes/sec/cm2
Rationale 2: The pulmonary system is a low-pressure system. The pressure of the vascular system is measured in dynes/sec/cm2 due to factors of flow, resistance, and time. This is the normal value for pulmonary vascular resistance.
The nurse notices that a patient with an arterial line has an elevated partial thromboplastin time (PTT) and is not on anticoagulation therapy. The nurse would: 1. Take the patient for an immediate V/Q scan. 2. Assess for the presence of a deep vein thrombosis. 3. Change the heparinized saline solution in the pressure bag for the arterial line to a normal saline solution. 4. Ask for an order to begin Lovenox therapy.
Rationale 3: Heparinized solutions are contraindicated in patients with coagulation deficiencies or heparin- induced thrombocytopenia.
A patient's systemic vascular resistance (SVR) has dangerously decreased. The nurse would expect to administer which medications? 1. Furosemide (Lasix) and dopamine 2. Nitroprusside and furosemide (Lasix) 3. Dopamine and norepinephrine (Levophed) 4. Nitroglycerin and digoxin (Lanoxin)
Rationale 3: If the SVR is low, there is massive peripheral vasodilation. These meds will increase vasomotor tone as well as increase blood pressure.
Prior to the insertion of an arterial line in the radial artery, which assessment would the nurse perform? '1. Homan's test 2. Kernig's test 3. Allen's test 4. Leopold's maneuver
Rationale 3: The Allen's test detects the patency of the ulnar artery. This is to ensure that there is adequate blood flow to the hand in the event the radial artery becomes occluded.
A patient's hemodynamic parameters include the following: right atrial pressure (RAP) of 13 mm Hg, pulmonary 2artery wedge pressure (PAWP) of 8 mm Hg, systemic vascular resistance (SVR) of 1,000 dynes/sec/cm , cardiac output (CO) of 4.9 L/min, cardiac index (CI) of 3.5 L/min, and pulmonary vascular resistance (PVR) of 280 dynes/sec/cm . Which heart function should cause the nurse concern? 1. Afterload 2. Left heart contractility 3. Right heart contractility 4. Heart rate
Rationale 3: The RAP reflects the amount of blood returning to the right atrium and is a measurement of preload. The elevated PVR is a reflection of the pressure within the right ventricle and is the amount of pressure needed for the right ventricle to eject blood into the PA. The elevated RAP and PVR indicate a problem with right heart contractility and is most likely related to right heart failure.
When observing the waveform of an arterial line, the nurse notes the presence of a dicrotic notch. The nurse knows this due to: 1. Pulmonic valve opening 2. Mitral valve closure 3. Aortic valve closure 4. Tricuspid valve closure
Rationale 3: The aortic valve closes and the mitral and tricuspid valves open in preparation for ventricular filling. The pulmonic valve closes at the same time as the aortic valve.
Which of the following actions has the highest priority for maintaining safety when caring for a patient with a PA catheter? 1. Obtain pressures per protocol. 2. Administer fluids and medications via pump. 3. Maintain asepsis when providing line care. 4. Obtain lab values as ordered.
Rationale 3: The presence of all invasive lines can lead to infection and sepsis. Preventing infection is the highest priority in maintaining patient safety.
The nurse identifies pulsus paradoxus on a patient's arterial pressure waveform monitoring when: 1. The waveform has tall, tented waves. 2. The pulse pressure is above 20 mm Hg on exhalation. 3. There is a decrease of more than 10 mm Hg in the arterial waveform before inhalation. 4. There is a single, nonperfused beat.
Rationale 3: There is a change in intrathoracic pressure that affects the filling of the ventricles, which is reflected in the arterial pressure.
A patient asks the nurse, "What is blood pressure?" The nurse would most appropriately respond: 1. "A measurement that should always be 120/80 unless complications are present." 2. "The amount of pressure exerted on your veins by the blood." 3. "A measurement that takes into consideration the amount of blood that your heart is pumping and the size of the vessel diameter the heart must pump against." 4. "A complex measurement that should only be discussed with your health care provider."
Rationale 3: This is understandable to the patient as well as accurate.
What should the nurse monitor in response to a change in SVO readings? 1. Potassium level 2. Glucose level 3. Sodium level 4. Hemoglobin level
Rationale 4: Oxygen is carried by hemoglobin; this value can influence and is reflected by the SVO2 level.
In order to correctly calculate cardiac output, the nurse should: 1. Only take two measurements and then average the two readings. 2. Take one measurement to prevent fluid volume overload. 3. Obtain five measurements and record the highest reading. 4. Take three to five measurements and take the average of the three readings that are within 10% of one another.
Rationale 4: There could be inconsistency on both temperature and technique. The average of the three closest measurements is standard to reflect accuracy.
How will the nurse calculate a patient's mean arterial pressure (MAP)? 1. Dividing the systolic pressure by the diastolic pressure 2. Averaging three of the patient's blood pressures over a 6-hour period 3. Dividing the diastolic pressure by the pulse pressure 4. Adding the systolic pressure and two diastolic pressures and then dividing by 3
Rationale 4: This is the gold standard for measuring MAP and it reflects the time the heart is in diastole during the cardiac cycle.
What will the nurse use to measure the contractility of the left side of a patient's heart? 1. Left atrial pressure 2. Pulmonary artery wedge pressure 3. Systemic vascular resistance 4. Left ventricular stroke work index
Rationale 4: This reflects the stretch and force of contraction of the heart muscle.
A patient has a lactate level of 8 mmol/L. The nurse realizes that this finding indicates: 1. Carbon dioxide exchange 2. Underuse of oxygen 3. Glucose metabolism 4. Tissue hypoxia
Rationale 4: When cells become oxygen deprived, anaerobic metabolism of glucose occurs, causing lactate formation instead of carbon dioxide and water. Elevated levels of lactate are a reliable indicator of tissue hypoxia.
