29 minute read
Chapter 08: Hemodynamic Monitoring
from TEST BANK for Introduction to Critical Care Nursing 7th Edition by Sole, Kelein, Mosley.
by StudyGuide
Sole: Introduction to Critical Care Nursing, 7th Edition
Multiple Choice
1. 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 1400 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 1400 dynes/sec/cm–5
DIF: Cognitive Level: Analyze/Analysis
OBJ: Identify normal hemodynamic values.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
NURSINGTB.COM
REF: p. 137 | Table 8-1 | Box 8-8 a. Diuretics b. Intravenous fluids c. Negative inotropic agents d. Vasopressors
2. 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?
ANS: B
Low pulmonary artery occlusion pressures usually indicate volume depletion, so intravenous fluids would be indicated. A normal hourly urine output is 1 mL/kg or at least 30 mL/hour, so this is another indication that the patient is volume depleted. 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.
DIF: Cognitive Level: Analyze/Analysis
REF: p. 149 | Box 8-1
OBJ: Articulate appropriate nursing actions for patients with altered hemodynamic values.
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity a. Apply a pressure dressing to the insertion site. b. Ensure that all tubing connections are tightened. c. Obtain a portable x-ray to confirm placement. d. Restrain the affected extremity for 24 hours.
3. The nurse is caring for a patient who has had an arterial line inserted. To reduce the risk of complications, what is the priority nursing intervention?
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; radiography is 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.
DIF: Cognitive Level: Apply/Application REF: p. 144
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Physiological Integrity
4. 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?
NURSINGTB.COM a. Increase supplemental oxygen and notify respiratory therapy. b. Notify the provider 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 manifestations do not warrant provider 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.
DIF: Cognitive Level: Analyze/Analysis
OBJ: Analyze conditions that alter hemodynamic values.
TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Physiological Integrity
REF: pp. 140-141
5. 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, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vascular resistance of 3000 dynes/sec/cm a. Blood transfusion b. Furosemide c. Dobutamine infusion d. Dopamine hydrochloride infusion
5, and a hematocrit of 20%. The nurse anticipates administration of which the following therapies or medications?
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.
DIF: Cognitive Level: Analyze/Analysis REF: p. 137 | Table 8-1 | Box 8-8
OBJ: Articulate appropriate nursing actions for patients with altered hemodynamic values.
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity a. Apply 50% oxygen via Venturi mask. b. Insert an indwelling urinary catheter. c. Begin a dobutamine infusion. d. Obtain stat cardiac enzymes and troponin.
6. 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, a cardiac output of 2.6 L/min and a cardiac index of 1.9 L/min/m2. Which provider order is of the highest priority?
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 infusion to improve cardiac output, possibly reducing pulmonary artery occlusion pressures. The other treatments may be important, depending on other patient data, but the dobutamine infusion is the most important at this time.
DIF: Cognitive Level: Analyze/Analysis
REF: p. 150 | Box 8-8
OBJ: Articulate appropriate nursing actions for patients with altered hemodynamic values.
TOP: Nursing Process Step: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity 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
7. 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?
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.
DIF: Cognitive Level: Apply/Application REF: pp. 143-144
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity 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.
8. The provider 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?
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 the 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 but unnecessary after catheter discontinuation.
NURSINGTB.COM
DIF: Cognitive Level: Understand/Comprehension
REF: p. 144
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Physiological Integrity 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.
9. 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?
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.
DIF: Cognitive Level: Remember/Knowledge
REF: p. 146
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity 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.
10. 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?
ANS: C
Balloon inflation should never be forced because the PAC may have migrated farther into the pulmonary artery, creating resistance to balloon inflation. Verification of proper line placement 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.
DIF: Cognitive Level: Apply/Application
REF: pp. 149-150
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
NURSINGTB.COM
TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Physiological Integrity 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
11. 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?
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.
DIF: Cognitive Level: Apply/Application
REF: Box 8-2
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity 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.
12. 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?
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 aspiration of tube feeding, 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.
NURSINGTB.COM
DIF: Cognitive Level: Apply/Application
REF: p. 141
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Physiological Integrity a. “The catheter will provide multiple sites to give intravenous fluid.” b. “The catheter will allow the provider 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.”
13. 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?
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.
DIF: Cognitive Level: Understand/Comprehension
REF: p. 149 | Box 8-1
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Evaluation
MSC: NCLEX Client Needs Category: Physiological Integrity 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.
14. 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?
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 positioning is maintained.
DIF: Cognitive Level: Analyze/Analysis
NURSINGTB.COM
REF: p. 149 | Box 8-1
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Physiological Integrity 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
15. 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?
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 and 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 mm Hg and a normal oxygen saturation does not require immediate treatment.
DIF: Cognitive Level: Analyze/Analysis
OBJ: Analyze conditions that alter hemodynamic values.
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity
REF: Table 8-1 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.
16. 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)?
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. Cleansing 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 but does not reduce the risk of infection.
DIF: Cognitive Level: Apply/Application
REF: p. 142
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention
NURSINGTB.COM
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 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.
17. During insertion of a pulmonary artery catheter, the provider asks the nurse to assist by inflating the balloon with 1.5 mL of air. As the provider advances the catheter, the nurse notices premature ventricular contractions on the monitor. What is the best action by the nurse?
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 (or amiodarone) may be necessary to suppress the irritated ventricle and should be readily available. Withdrawal 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.
DIF: Cognitive Level: Apply/Application
REF: p. 146
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Physiological Integrity 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
18. Following insertion of a pulmonary artery catheter (PAC), the provider requests the nurse obtain a blood sample for mixed venous oxygen saturation (SvO2). Which action by the nurse best ensures the obtained value is accurate?
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.
DIF: Cognitive Level: Apply/Application
REF: p. 152
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
NURSINGTB.COM
TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Physiological Integrity 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
19. 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?
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.
DIF: Cognitive Level: Analyze/Analysis
OBJ: Identify normal hemodynamic values.
TOP: Nursing Process Step: Assessment
REF: p. 136
MSC: NCLEX Client Needs Category: Physiological Integrity Physiological Adaptation 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.
20. 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 orders?
ANS: D
A central venous pressure of 1 mm Hg, pulmonary artery occlusion pressure of 3 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 and obtaining serum blood gas and electrolyte samples, although not a priority, are appropriate interventions.
DIF: Cognitive Level: Analyze/Analysis
REF: Table 8-1
OBJ: Articulate appropriate nursing actions for patients with altered hemodynamic values.
TOP: Nursing Process Step: Diagnosis
MSC: NCLEX Client Needs Category: Physiological Integrity
21. The charge nurse has a 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?
NURSINGTB.COM 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 dysrhythmias are conditions in which pulse contour analysis systems are either inaccurate or contraindicated.
DIF: Cognitive Level: Analyze/Analysis
REF: pp. 155-157
OBJ: Explain the clinical relevance and methods of measuring cardiac output.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity 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 to monitor the patient. d. Perform an immediate dynamic response test; obtain a chest x-ray.
22. The provider prescribes a pulmonary artery occlusive pressure reading (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?
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 to monitor 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.
NURSINGTB.COM
DIF: Cognitive Level: Analyze/Analysis
REF: p. 148 | Fig 8-18A
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity 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.
23. 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?
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.
DIF: Cognitive Level: Apply/Application
REF: p. 136
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity a. Limit the patient’s supine position to no more than 10 seconds. b. Administer antianxiety 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.
24. The nurse is caring for a patient with an admitting diagnosis 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?
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 who becomes anxious and tachypneic when flat. Administering antianxiety medications is not standard of care for obtaining hemodynamic pressures. Encouraging slow, deep breaths while supine may inappropriately alter hemodynamic readings by altering intrathoracic pressure.
DIF: Cognitive Level: Apply/Application
REF: pp. 140-141
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
NURSINGTB.COM
TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Physiological Integrity 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.
25. 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. Before obtaining a cardiac output, which action is most important for the nurse to complete?
ANS: B
To ensure accurate measurement, zero referencing of the transducer system is a priority action after moving a patient and should be completed before obtaining readings. A pulmonary artery catheter occlusion pressure should be documented before obtaining a cardiac output, but without zero referencing the system following movement 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 before obtaining a cardiac output. The nurse injects 5-10 mL of normal saline into the proximal port in order to measure the cardiac output; this is not a step done before obtaining the measurement.
DIF: Cognitive Level: Apply/Application
REF: pp. 140-141
OBJ: Analyze the conditions that alter hemodynamic values.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Adaptation 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
26. 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?
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.
DIF: Cognitive Level: Remember/Knowledge REF: Table 8-1
OBJ: Identify normal hemodynamic values.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 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.
27. 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?
NURSINGTB.COM
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.
DIF: Cognitive Level: Understand/Comprehension REF: p. 157
OBJ: Analyze the conditions that alter hemodynamic values.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Adaptation 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.
28. 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?
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 inappropriate 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.
DIF: Cognitive Level: Apply/Application
REF: p. 144
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Adaptation a. Document all waveform values. b. Limit the pressure tubing length. c. Zero reference the system daily. d. Ensure alarm limits are turned on.
29. 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?
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. Hemodynamic 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.
DIF: Cognitive Level: Apply/Application
REF: Box 8-4
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment 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.
30. 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?
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.
DIF: Cognitive Level: Apply/Application
REF: Box 8-9
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment
Multiple Response
1. 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.
e. Inflate and deflate the balloon on an hourly schedule
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. There is no reason to inflate and deflate the catheter’s balloon unless measurements are being obtained.
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DIF: Cognitive Level: Apply/Application
REF: p. 149 | Box 8-1
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Physiological Integrity 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.
2. The nurse is preparing to obtain a right atrial pressure (RAP/CVP) reading. What are the most appropriate nursing actions? (Select all that apply.)
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.
DIF: Cognitive Level: Apply/Application
REF: p. 138 | Fig 8-7
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Physiological Integrity 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 provider. d. Monitor the patient’s cardiac rhythm throughout the procedure. e. Obtain informed consent by informing the patient of procedural risks.
3. 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.)
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 provider 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 provider and should occur before the procedure begins.
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DIF: Cognitive Level: Apply/Application
REF: p. 147
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Physiological Integrity 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 e. Ensuring all junctions remain tightly connected
4. Which nursing actions are most important for a patient with a right radial arterial line? (Select all that apply.)
ANS: A, B, C, E
Options A, B, C, and E 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.
DIF: Cognitive Level: Understand/Comprehension
REF: pp. 143-144
OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices.
TOP: Nursing Process Step: Intervention
MSC: NCLEX Client Needs Category: Physiological Integrity a. Exercise b. Hypovolemia c. Myocardial infarction d. Shock e. Fever
5. Which of the following situations may result in a low cardiac output and low cardiac index? (Select all that apply.)
ANS: B, C, D
Hypovolemia, myocardial infarction, and shock often result in a decreased cardiac output. Cardiac output is usually increased with exercise and fever.
DIF: Cognitive Level: Remember/Knowledge
OBJ: Analyze conditions that alter hemodynamic values.
TOP: Nursing Process Step: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity
REF: Box 8-8
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