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NURSING 2765/NURSING 2765 Questions and Answers/University of North Georgia, Gainesville
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NURSING 2765/NURSING 2765 Questions and Answers/University of North Georgia, Gainesville
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The nurse is caring for a 100-kg patient being monitored with a pulmonary arterycatheter. 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
a. Cardiac index (CI) of 1.2 L/min/m3
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
b. Intravenous fluids
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.
b. Ensure all tubing connections are tightened.
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.
d. Zero reference and level the catheter at the phlebostatic axis.
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
b. Numbness and tingling in the left hand
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.
b. Apply pressure to the insertion site for 5 minutes.
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.
c. The distal tip of the catheter is in the appropriate position.
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.
c. Deflate the balloon and obtain a chest x-ray study to determine line placement.
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
a. Diminished breath sounds over left lung field
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.
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.
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."
b. "The catheter will allow the physician to better manage fluid therapy."
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.
d. Place the patient with the head of bed elevated 30 degrees and record the PAOP just
before the increase in pressures during inhalation.
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
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
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.
a. Review daily the necessity of the central venous catheter.
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
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