Nokea
The nurse is assisting with insertion of a pulmonary artery (PA) catheter in a patient. Which of the following data identifies that the catheter is correctly placed?
- A. Monitor shows a typical PAOP tracing.
- B. PA waveform is observed on the monitor.
- C. Systemic arterial pressure tracing appears on the monitor.
- D. Catheter has been inserted to the 22-cm marking on the line.
Correct Answer: A
Rationale: One of the purposes of a PA line is to measure PAOP, so the catheter is floated through the pulmonary artery until the dilated balloon wedges in a distal branch of the pulmonary artery, and the PAOP readings are available. After insertion, the balloon is deflated and the PA waveform will be observed. Systemic arterial pressures are obtained using an arterial line. The length of catheter needed for insertion will vary with patient size.
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The nurse notes thick, white respiratory secretions from a patient who is receiving mechanical ventilation. Which of the following interventions will be most effective in resolving this problem?
- A. Suction the patient every hour.
- B. Reposition the patient every 2 hours.
- C. Add additional water to the patient's enteral feedings.
- D. Instill 5 ml of sterile saline into the endotracheal tube (ET) before suctioning.
Correct Answer: C
Rationale: Because the patient's secretions are thick, better hydration is indicated. Suctioning every hour without any specific evidence for the need will increase the incidence of mucosal trauma and would not address the etiology of the ineffective airway clearance. Instillation of saline does not liquefy secretions and may decrease the SpO2. Repositioning the patient is appropriate but will not decrease the thickness of secretions.
While family members are visiting, a patient has a cardiac arrest and is being resuscitated. Which of the following actions by the nurse is best?
- A. Ask family members if they wish to remain in the room during the resuscitation.
- B. Explain to family members that watching the resuscitation will be very stressful.
- C. Assign a staff member to wait with family members just outside the patient room.
- D. Escort family members quickly out of the patient room and then remain with them.
Correct Answer: A
Rationale: Research indicates that family members want the option of remaining in the room during procedures such as CPR and that this decreases anxiety and facilitates grieving. The other options may be appropriate if the family decides not to remain with the patient.
The nurse is caring for a patient who has an intra-aortic balloon pump in place. Which of the following actions should be included in the plan of care?
- A. Avoid the use of anticoagulant medications.
- B. Keep the head of the bed elevated 45 degrees.
- C. Measure the patient's urinary output every hour.
- D. Provide passive range of motion for all extremities.
Correct Answer: C
Rationale: Monitoring urine output will help determine whether the patient's cardiac output has improved and also help monitor for balloon displacement. The head of the bed should be no higher than 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the extremity with the balloon insertion site to prevent displacement of the balloon.
The nurse is caring for a patient with heart failure requiring a ventricular assist device (VAD) implanted and is waiting for cardiac transplantation. Which of the following actions should the nurse include in the plan of care?
- A. Administer of immuno-suppressive medications.
- B. Monitor the surgical incision for signs of infection.
- C. Teach the patient the reason for continuous bed rest.
- D. Prepare the patient to have the VAD in place permanently.
Correct Answer: B
Rationale: The insertion site for the VAD provides a source for transmission of infection to the circulatory system and requires frequent monitoring. Patients with VADs are able to have some mobility and may not be on bed rest. The VAD is a bridge to transplantation, not a permanent device. Immuno-suppression is not necessary for nonbiological devices like the VAD.
To determine the effectiveness of medications that a patient has received to reduce left ventricular afterload, which of the following hemodynamic parameters should the nurse monitor?
- A. Central venous pressure (CVP)
- B. Systemic vascular resistance (SVR)
- C. Pulmonary vascular resistance (PVR)
- D. Pulmonary artery wedge pressure (PAWP)
Correct Answer: B
Rationale: Systemic vascular resistance reflects the resistance to ventricular ejection, or afterload. The other parameters will be monitored, but do not reflect afterload as directly.