Nokea
When a patient's pulmonary artery catheter becomes wedged and does not reflect pulmonary artery pressures, which of the following actions should the nurse take?
- A. Reposition the patient and check for a pulmonary artery tracing.
- B. Deflate the balloon and flush the catheter with saline.
- C. Notify a health care provider or specially trained nurse.
- D. Increase the volume in the balloon to open the catheter.
Correct Answer: C
Rationale: When the catheter is in the wedge position, blood flow past the catheter is obstructed, placing the patient at risk for pulmonary infarction. A health care provider or specially trained nurse should be called to reposition the catheter. The other actions will not correct the wedging of the PA catheter.
You may also like to solve these questions
The nurse is caring for a patient with pulmonary hypertension. Which of the following parameters should the nurse monitor as an index of right ventricular afterload?
- A. Mean arterial pressure (MAP)
- B. Central venous pressure (CVP)
- C. Pulmonary vascular resistance (PVR)
- D. Pulmonary artery wedge pressure (PAWP)
Correct Answer: C
Rationale: Pulmonary vascular resistance and pulmonary artery pressure are indexes of right ventricular afterload. The other parameters do not directly assess for right ventricular afterload.
The nurse is caring for a patient who has an arterial catheter in the radial artery to monitor blood pressure. Which of the following information obtained by the nurse is most important to report to the health care provider?
- A. The patient has a positive Allen test.
- B. The mean arterial pressure (MAP) is 86 mm Hg.
- C. There is redness at the catheter insertion site.
- D. The dicrotic notch is visible in the waveform.
Correct Answer: C
Rationale: Redness at the catheter insertion site indicates possible infection. The Allen test is performed before arterial line insertion, and a positive test indicates normal ulnar artery perfusion. An MAP of 86 is normal and the dicrotic notch is normally present on the arterial waveform.
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.
The nurse is caring for an older-adult patient who has stabilized after being in the intensive care unit (ICU) for a week and is preparing for transfer to the step-down unit when the nurse notices that the patient has new onset confusion. Which of the following actions should the nurse implement?
- A. Inform the receiving nurse and then transfer the patient.
- B. Notify the health care provider and postpone the transfer.
- C. Administer PRN lorazepam and cancel the transfer.
- D. Obtain an order for restraints as needed and transfer the patient.
Correct Answer: A
Rationale: The patient's history and symptoms most likely indicate delirium associated with the sleep deprivation with sensory overload in the ICU environment. Informing the receiving nurse and transferring the patient is appropriate. Postponing the transfer is likely to prolong the delirium. Benzodiazepines and restraints contribute to delirium and agitation.
Which of the following actions should the nurse take when the low-pressure alarm sounds for a patient who has an arterial line in the right radial artery?
- A. Check the right hand for pallor.
- B. Assess for cardiac dysrhythmias.
- C. Flush the arterial line with saline.
- D. Rezero the monitoring equipment.
Correct Answer: B
Rationale: The low-pressure alarm indicates a drop in the patient's blood pressure, which may be caused by cardiac dysrhythmias. There is no indication to rezero the equipment. Pallor of the right hand would be caused by occlusion of the radial artery by the arterial catheter, not by low pressure. There is no indication of a need for flushing the line.