Nokea
The nurse is caring for an acutely ill patient who has central venous pressure monitoring in place. What intervention should be included in the care plan of a patient with CVP in place?
- A. Apply antibiotic ointment to the insertion site twice daily
- B. Change the site dressing whenever it becomes visibly soiled
- C. Perform passive range-of-motion exercises to prevent venous stasis
- D. Aspirate blood from the device once daily to test pH
Correct Answer: B
Rationale: Gauze dressings should be changed every 2 days or transparent dressings at least every 7 days and whenever dressings become damp, loosened, or visibly soiled. Passive ROM exercise is not indicated and it is unnecessary and inappropriate to aspirate blood to test it for pH. Antibiotic ointments are contraindicated.
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The patient has a homocysteine level ordered. What aspects of this test should inform the nurses care? Select all that apply.
- A. A 12-hour fast is necessary before drawing the blood sample
- B. Recent inactivity can depress homocysteine levels
- C. Genetic factors can elevate homocysteine levels
- D. A diet low in folic acid elevates homocysteine levels
- E. An ECG should be performed immediately before drawing a sample
Correct Answer: A,C,D
Rationale: Genetic factors and a diet low in folic acid, vitamin B6, and vitamin B12 are associated with elevated homocysteine levels. A 12-hour fast is necessary before drawing a blood sample for an accurate serum measurement. An ECG is unnecessary and recent inactivity does not influence the results of the test.
The physician has placed a central venous pressure (CVP) monitoring line in an acutely ill patient so right ventricular function and venous blood return can be closely monitored. The results show decreased CVP. What does this indicate?
- A. Possible hypovolemia
- B. Possible myocardial infarction (MI)
- C. Left-sided heart failure
- D. Aortic valve regurgitation
Correct Answer: A
Rationale: Hypovolemia may cause a decreased CVP. MI, valve regurgitation, and heart failure are less likely causes of decreased CVP.
The critical care nurse is caring for a patient with a central venous pressure (CVP) monitoring system. The nurse notes that the patients CVP is increasing. Of what may this indicate?
- A. Psychosocial stress
- B. Hypervolemia
- C. Dislodgment of the catheter
- D. Hypomagnesemia
Correct Answer: B
Rationale: CVP is a useful hemodynamic parameter to observe when managing an unstable patients fluid volume status. An increasing pressure may be caused by hypervolemia or by a condition, such as heart failure, that results in decreased myocardial contractility. Stress, dislodgement of the catheter, and low magnesium levels would not typically result in increased CVP.
The nurse is doing discharge teaching with a patient who has coronary artery disease. The patient asks why he has to take an aspirin every day if he doesnt have any pain. What would be the nurses best response?
- A. Taking an aspirin every day is an easy way to help restore the normal function of your heart
- B. An aspirin a day can help prevent some of the blockages that can cause chest pain or heart attacks
- C. Taking an aspirin every day is a simple way to make your blood penetrate your heart more freely
- D. An aspirin a day eventually helps your blood carry more oxygen that it would otherwise
Correct Answer: B
Rationale: An aspirin a day is a common nonprescription medication that improves outcomes in patients with CAD due to its antiplatelet action. It does not affect oxygen carrying capacity or perfusion. Aspirin does not restore cardiac function.
The nurse is caring for a patient who is undergoing an exercise stress test. Prior to reaching the target heart rate, the patient develops chest pain. What is the nurses most appropriate response?
- A. Administer sublingual nitroglycerin to allow the patient to finish the test
- B. Initiate cardiopulmonary resuscitation
- C. Administer analgesia and slow the test
- D. Stop the test and monitor the patient closely
Correct Answer: D
Rationale: Signs of myocardial ischemia would necessitate stopping the test. CPR would only be necessary if signs of cardiac or respiratory arrest were evident.