Chapter 31 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 31

Question 1

Type: MCSA

The nurse is in orientation for a new job caring for patients in the intensive care area. Which statement indicates to the preceptor that the new nurse needs more information about hemodynamic monitoring?

1. Data from hemodynamic monitoring can be used to evaluate the patients progress.

2. Hemodynamic monitoring data can help to guide fluid administration and prevent fluid overload.

3. Hemodynamic monitoring data can be used to aid in the diagnosis of lung disorders.

4. One drawback of hemodynamic monitoring is that the catheter must go through the heart and into the pulmonary artery.

Correct Answer: 4

Rationale 1: One of the purposes of hemodynamic monitoring is evaluating patient response to therapy.

Rationale 2: One of the purposes of hemodynamic monitoring is guiding therapy to minimize or correct dysfunction.

Rationale 3: Hemodynamic monitoring can help to diagnose and treat a number of disorders, including disorders of the lung.

Rationale 4: The pulmonary artery catheter does go through the heart and into the pulmonary artery; however, hemodynamic monitoring can also be accomplished through a peripheral arterial line.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 31-1

Question 2

Type: MCSA

A family member of a critically ill patient is verbalizing the purpose of hemodynamic monitoring. Which statement indicates that the family member needs more education?

1. The hemodynamic monitor can measure how much blood is in the arteries and veins.

2. The hemodynamic monitor can measure how much blood comes out of the heart each minute.

3. The hemodynamic monitor can measure how much oxygen is left in the blood after it circulates through the body.

4. The hemodynamic monitor can measure how much pressure is in the heart.

Correct Answer: 1

Rationale 1: The pressure monitoring can see trends in pressure, which may indirectly be related to volume or to decreased vascular resistance. The nurse and physician would need to interpret this data to determine the cause of the change.

Rationale 2: An example of such a measurement is thermodilution cardiac output.

Rationale 3: An example of such a measurement is continuous mixed venous oxygen saturation.

Rationale 4: An example of such a measurement is pulmonary artery occlusion pressure (PAOP), an indirect measurement of left ventricular end-diastolic pressure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 31-1

Question 3

Type: MCSA

A patient is concerned about the arterial line waveform pattern because there is a break in the downward slope of the pattern and

something must be wrong because it is not a smooth line. What is the nurses best response?

1. What you are seeing is called a dicrotic notch, and it means the beginning of the resting phase of your heart.

2. It is nothing for you to be concerned about. It is just a measurement of your blood pressure.

3. You are right. I will see if you are prescribed any medication for that problem.

4. You are seeing the strongest part of your heart muscle, which is the first number of a blood pressure reading.

Correct Answer: 1

Rationale 1: The dicrotic notch represents closure of the aortic valve and distinguishes the beginning of diastole or the resting phase of the heart ventricles.

Rationale 2: The nurse should not minimize the patients concern.

Rationale 3: The nurse should not agree with the patient or suggest that the patient might need medication.

Rationale 4: The dicrotic notch does not signify the first number of a blood pressure reading.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-1

Question 4

Type: MCSA

The role of the nurse who is caring for a patient with invasive hemodynamic monitoring includes which important interventions?

1. Keeping IV solutions at atmospheric pressure so the monitor obtains accurate patient pressures

2. Frequent reassessment and evaluation of data in order to tailor therapies to the patient

3. Using the hemodynamic line for monitoring pressures and not for infusing IV fluids

4. Zero referencing the transducer to the level of the radial artery

Correct Answer: 2

Rationale 1: IV solutions are kept at 300 mmHg.

Rationale 2: An important nursing intervention is the frequent reassessment and evaluation of data in order to tailor therapies to the patient. Fluids and medications are often changed when the nurse reports changes in hemodynamic data to the health care provider.

Rationale 3: Fluids are infused constantly through the system to prevent clotting of the line.

Rationale 4: The hemodynamic transducer is zeroed using the phlebostatic axis as a reference.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-2

Question 5

Type: MCSA

A patient with an arterial line has just been turned and repositioned. After leveling the transducer, what should the nurse do next?

1. Turn the stopcock closest to the patient to the neutral position.

2. Zero the transducer.

3. Increase the arterial line infusion to 5 mL/hour.

4. Prime the transducer system.

Correct Answer: 2

Rationale 1: The stopcock is turned to the neutral position after the transducer has been zeroed.

Rationale 2: The transducer should be zeroed after turning the patient, once the transducer has been leveled.

Rationale 3: The arterial line infusion should be set at 1 to 3 mL/hour.

Rationale 4: Priming the transducer system ensures that air bubbles are removed from the system. This is done prior to leveling the

transducer.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

Question 6

Type: MCSA

When comparing arterial, central venous, and pulmonary arterial pressures, the nurse keeps which factor in mind?

1. It is not a good idea to measure the patients blood pressure from the arterial waveform tracing.

2. The pressures in the superior and inferior vena cava are lower than the pressure in the right atrium of the heart.

3. The normal pressure in the right atrium of the heart is very low, 4 to 6 mmHg.

4. The small vessels of the pulmonary arteries are under more pressure than systemic arterial blood pressure.

Correct Answer: 3

Rationale 1: The arterial waveform tracing is an accurate way to measure blood pressure.

Rationale 2: The normal pressure in the right atrium of the heart is equal to the pressures in the superior and inferior vena cava because there is no valve between the vena cava and the right atrium.

Rationale 3: The normal pressure in the right atrium of the heart is very low, 4 to 6 mmHg.

Rationale 4: Pulmonary arterial pressure is normally lower than systemic arterial blood pressure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-2

Question 7

Type: MCSA

A critically ill patient is admitted for the treatment of sepsis. The right arterial BP is 90/60, the central venous pressure is 2, and the pulmonary arterial pressure is 20/8. What assessment can the nurse make from this data?

1. The patient may require additional fluids because all pressures are low.

2. The pressure in the lungs is high even though the other pressures are low. The doctor should be notified and stat X-ray expected.

3. The patient is stable and should continue to be monitored hourly because of the sepsis.

4. The line should be flushed and rezeroed before an evaluation can be made.

Correct Answer: 1

Rationale 1: The arterial, central venous, and pulmonary arterial pressures are all low. Sepsis is a type of distributive shock. The nurse would expect to give a fluid bolus in this situation as well as initiate or continue other therapies for sepsis.

Rationale 2: The pressure in the lungs is not high.

Rationale 3: These pressures do not reflect stability. An intervention is indicated.

Rationale 4: The assessment does not indicate a need to flush and rezero the equipment.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-3

Question 8

Type: MCSA

Which information is essential for the nurse to keep in mind when monitoring a patients central venous pressure?

1. It is better to look at current numbers for central venous pressure monitoring rather than trends.

2. Central venous pressure is a direct measurement of systemic vascular resistance.

3. A decreasing trend in central venous pressure may indicate right heart failure.

4. An increasing trend in central venous pressure may result from fluid building in the lungs.

Correct Answer: 4

Rationale 1: It is more accurate to look at trends than at one CVP reading.

Rationale 2: CVP is not a direct measurement of systemic vascular resistance.

Rationale 3: Right heart failure would cause an increasing CVP.

Rationale 4: As pressure in the lungs increases, volume in the right heart will increase, which will increase the CVP.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 31-5

Question 9

Type: MCSA

The nurse is preparing to inflate a pulmonary artery catheter (PAC) balloon while it is located in the pulmonary artery. What assessment is possible from this action?

1. When inflated, the catheter indirectly measures pressures in the left side of the heart.

2. When inflated, the catheter measures the pressure in the right side of the heart.

3. When inflated, the catheter indirectly measures the cardiac index.

4. When inflated, the catheter measures cardiac output through thermodilution.

Correct Answer: 1

Rationale 1: Inflating the balloon in the pulmonary artery catheter indirectly measures pressures in the left side of the heart.

Rationale 2: Inflating the balloon in the pulmonary artery catheter measures other pressures.

Rationale 3: The cardiac index is the cardiac output divided by the body surface area.

Rationale 4: Cardiac output is measured though a thermistor within the catheter.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

Question 10

Type: MCSA

A patients central venous pressure reading is 8 mmHg. The nurse understands this reading reflects which physiological parameter?

1. The blood pressure within the right atrium

2. The blood pressure within the pulmonary artery

3. The blood pressure within the left ventricle

4. The blood pressure within the left atrium

Correct Answer: 1

Rationale 1: The central venous pressure reflects the blood pressure of the vena cava and the right atrium.

Rationale 2: The central venous pressure does not reflect pressures with the pulmonary artery.

Rationale 3: The central venous pressure is not the same as left ventricular pressure.

Rationale 4: The central venous pressure is not the same as left atrial pressure.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-3

Question 11

Type: MCSA

The nurse caring for a patient with hemodynamic monitoring would collaborate with a physician colleague to implement which intervention?

1. Changing the dosages (titrating) of medications based on changes in hemodynamic pressures

2. Using sterile technique to clean the site of insertion of the catheter and changing the dressing

3. Inflating the balloon in the pulmonary artery to obtain pulmonary artery occlusion pressures

4. Advancing the catheter if the radiologist determines it is not in the pulmonary artery

Correct Answer: 4

Rationale 1: It is within the nurses scope of practice to titrate medications based on patient response to therapy.

Rationale 2: Cleaning and dressing the insertion site of a hemodynamic catheter is within the nurses scope of practice.

Rationale 3: Inflating the pulmonary artery catheter balloon to obtain pressure readings is within the nurses scope of practice.

Rationale 4: The nurse does not advance the catheter through the heart.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

Question 12

Type: MCSA

While caring for a patient with a right radial arterial line, the nurse assesses that the fingers of the right hand are cool, pale, and dusky. Which intervention would be important to do first?

1. Obtain a blood pressure in the left arm.

2. Try to obtain a pulse using Doppler ultrasound.

3. Notify the physician stat.

4. Flush the arterial catheter and zero the line.

Correct Answer: 3

Rationale 1: Obtaining a blood pressure will not affect the outcome of this emergency situation.

Rationale 2: The patient is exhibiting symptoms of arterial compromise. Even if a pulse is obtainable with Doppler, it is obvious that emergency action must be taken.

Rationale 3: The health care provider must be notified stat, and the line needs to be discontinued. Symptoms including cool, pale, and dusky skin indicate arterial occlusion, and this is a medical emergency. Loss of arterial circulation will cause loss of the limb distal to the occlusion unless circulation can be restored.

Rationale 4: Flushing the arterial catheter and zeroing the line will not be sufficient intervention in this situation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

Question 13

Type: MCSA

While caring for a patient with a pulmonary arterial catheter, the nurse notes that the number of centimeters of exposed catheter has decreased. What nursing action is indicated?

1. Report this finding immediately; the patient may need another chest X-ray to check for placement.

2. Flush the ports.

3. Obtain a pulmonary artery occlusion pressure.

4. Zero balance the system.

Correct Answer: 1

Rationale 1: The distance the catheter is inserted should be documented and serves as a reference to other care providers. If the length changes, the change should be reported immediately because it could mean that the catheter has advanced and could puncture a structure within the vasculature.

Rationale 2: If the catheter is not in correct position, flushing the ports is contraindicated.

Rationale 3: If the catheter is not in the correct position, readings are inaccurate. This is not the priority intervention.

Rationale 4: There is no reason to zero balance the system at this time.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

Question 14

Type: MCSA

The nurse has noted increasing afterload in a patient in the ICU. How would the nurse expect this increase to affect the patients cardiac output?

1. If afterload is high, cardiac output will be increased because the heart rate increases during afterload.

2. If afterload is high, cardiac output will be increased due to the increased volume in the heart.

3. If afterload is high, cardiac output will be decreased due to high systemic vascular resistance.

4. If afterload is high, cardiac output will be decreased due to decreased contractility.

Correct Answer: 3

Rationale 1: Afterload is a measure of pressure, not a cardiac event, so to say that heart rate increases during afterload is incorrect.

Rationale 2: If the increased volume in the heart has to overcome additional systemic vascular resistance (afterload), the cardiac output will not increase.

Rationale 3: Afterload measures the pressure that is needed to eject blood out of the heart. Systemic vascular resistance is the main factor that affects afterload. High resistance impedes flow and decreases cardiac output.

Rationale 4: Contractility may increase with high afterload to compensate for low stroke volume, or it may decrease if the patient decompensates. Either way, decreased contractility does not cause high afterload.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-5

Question 15

Type: MCSA

The nurse is attempting to increase contractility to improve cardiac output in a patient with acute exacerbation of heart failure. Which measure would be helpful to improve cardiac contractility?

1. Administering magnesium sulfate

2. Encouraging the patient to exercise

3. Giving the patient a beta-adrenergic blocking medication

4. Correcting oxygenation and mild respiratory acidosis

Correct Answer: 4

Rationale 1: Magnesium sulfate is a smooth muscle relaxer and would not increase cardiac contractility.

Rationale 2: Encouraging exercise in a patient with acute exacerbation of heart failure is an unsafe intervention.

Rationale 3: Beta-adrenergic blocking medication would decrease cardiac contractility.

Rationale 4: Achieving normal oxygenation and correcting acidosis would improve cardiac contractility.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-5

Question 16

Type: MCSA

A patient has been diagnosed with an increase in afterload and a CVP reading of 7 mmHg. What should the nurse include in this patients plan of care?

1. Provide plasma.

2. Provide intravenous fluids.

3. Provide diuretic therapy as prescribed.

4. Encourage an increase in fluids by mouth.

Correct Answer: 3

Rationale 1: Plasma might be indicated for a patient who is diagnosed with a decrease in preload and hypovolemia.

Rationale 2: Intravenous fluids might be indicated for a patient who is diagnosed with a decrease in preload and hypovolemia.

Rationale 3: Excessive preload is evidenced by a CVP reading of greater than 6 mmHg. The patient has excessive circulation, which strains the heart, increases the workload of the heart, and increases myocardial oxygen demands. Diuretic therapy would be indicated for this patient.

Rationale 4: Oral fluids might be indicated for a patient who is diagnosed with a decrease in preload and hypovolemia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 31-5

Question 17

Type: MCSA

The nurse is caring for a patient who has invasive hemodynamic monitoring. What is the nurses highest priority of care for this patient?

1. Prevent infection at the catheter site by changing the dressing as prescribed.

2. Set alarm limits and turn monitor alarms on.

3. Explain to family members why the monitoring is in use.

4. Coil IV tubing on the bed.

Correct Answer: 2

Rationale 1: Prevention of infection by changing dressings is important but not the priority of care.

Rationale 2: Alarms should never be turned off as they are safety devices that warn of a disconnected line or hemodynamic instability. When an alarm sounds, the nurse should always investigate the cause.

Rationale 3: Keeping family members informed about monitoring is important, but not the priority of care.

Rationale 4: Coiling the IV tubing on the bed is contraindicated.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

Question 18

Type: MCSA

The patient in the critical care area has an invasive hemodynamic pressure monitoring line. Where would the nurse mark the patients phlebostatic axis?

1. Fourth intercostal space, halfway between the left anterior and posterior chest walls

2. Fifth intercostal space, midclavicular line

3. Second intercostal space at the anterior chest wall

4. Right side of sternum just below the sternal notch

Correct Answer: 1

Rationale 1: The phlebostatis axis is marked halfway between the left anterior and posterior chest walls (midaxillary line) at the fourth intercostal space.

Rationale 2: The fifth intercostal space, midclavicular line, is the position of the apex of the heart and is where auscultation for the apical pulse should be performed.

Rationale 3: The second intercostal space is too high to use as a landmark for the atrium.

Rationale 4: The right side of the sternum just below the sternal notch is the location of the second intercostal space.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

Question 19

Type: MCSA

The nurse is caring for a patient in the critical care area whose fluid volume status needs to be assessed closely. The nurse would expect which type of monitoring to be used?

1. Arterial pressure monitoring

2. Pulmonary artery pressure monitoring

3. Central venous pressure monitoring

4. Intra-aortic balloon pump monitoring

Correct Answer: 3

Rationale 1: Arterial pressure monitoring would not measure central venous pressure, which is essential for monitoring fluid volume status.

Rationale 2: Fluid volume can be monitored effectively with equipment that is less invasive than a pulmonary artery pressure monitor.

Rationale 3: Central venous pressure (CVP) monitoring can be accomplished with a central IV line and an IV pump or a monitoring system. It would be the least complicated method to monitor fluid status.

Rationale 4: An intra-aortic balloon pump would not be used for pressure monitoring.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 31-1

Question 20

Type: MCSA

The intensive care unit nurse would expect pulmonary artery (PA) catheter monitoring to be used with a patient in which situation?

1. Cannot tolerate hemodynamic monitoring

2. Requires a peripheral intravenous catheter for vasoactive medication administration

3. Needs a central catheter for total parenteral nutrition

4. Requires evaluation of left ventricular pressures each shift

Correct Answer: 4

Rationale 1: PA catheters are a form of hemodynamic monitoring.

Rationale 2: The PA would not be used to administer vasoactive medications because it is a central arterial catheter, not a peripheral line.

Rationale 3: A PA catheter is not necessary to infuse total parenteral nutrition.

Rationale 4: Pulmonary artery (PA) catheters can be used to evaluate pulmonary artery and left ventricular pressures, measure cardiac output, and manipulate fluid volume status in acutely ill patients.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-1

Question 21

Type: FIB

A patients vital signs are heart rate 82, respirations 22, and blood pressure 90/52. If hemodynamic monitoring reveals the patients cardiac output to be 5330 mL/min, the nurse would calculate that stroke volume is _____ mL.

Standard Text:

Correct Answer: 65

Rationale : Cardiac output is equal to heart rate times stroke volume: 82x = 5330; x = 65.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-3

Question 22

Type: MCMA

The nurse wishes to calculate a patients cardiac index. Which patient information will the nurse require for this calculation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Age

2. Weight

3. Temperature

4. Height

5. Cardiac output

Correct Answer: 2,4,5

Rationale 1: Age is not a determinant of cardiac index.

Rationale 2: Weight is used to determine body surface area, which is used to calculate cardiac index.

Rationale 3: Temperature is not a determinant of cardiac index.

Rationale 4: Height is used to determine body surface area, which is used to calculate cardiac index.

Rationale 5: Cardiac output is used to calculate cardiac index.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-3

Question 23

Type: MCSA

Which finding would suggest to the nurse that the patient has a good cardiac reserve?

1. The patient is able to tolerate a gradual increase of pace during a treadmill exam.

2. The patient breathes in through the nose and out through the mouth when sitting quietly.

3. After cardiac rehabilitation exercises the patient sits in a chair to cool down.

4. The patient complains of pain in the legs after walking 100 yards.

Correct Answer: 1

Rationale 1: The hearts ability to respond to the bodys changing need for cardiac output is called cardiac reserve. Increasing the pace of walking would place demand on the heart to increase blood flow.

Rationale 2: This action does not represent a physical demand on the heart and therefore does not test cardiac reserve.

Rationale 3: This action takes place after exercise so it does not represent a demand on the heart and does not test cardiac reserve.

Rationale 4: This physical demand results in intermittent claudication, but is not associated with cardiac reserve.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-3

Question 24

Type: MCMA

The nurse educator is discussing hemodynamic monitoring with newly hired intensive care unit nurses. Which information regarding the importance of leveling the hemodynamic transducer should the educator provide?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The level of the transducer is set when the central venous catheter is initiated and should not be moved.

2. If the transducer is too high, pressure readings will be decreased.

3. The physician must be called in to level the transducer.

4. The transducer should be leveled with the phlebostatic axis point.

5. It the transducer is too low, the readings will be increased.

Correct Answer: 2,4,5

Rationale 1: The transducer should be leveled each time the patient is repositioned.

Rationale 2: A transducer that is set above the phlebostatic axis will result in pressure readings that are lower than actual readings.

Rationale 3: Leveling the transducer is a nursing responsibility.

Rationale 4: The phlebostatic axis point serves as a reference for the level of the transducer.

Rationale 5: A transducer that is set below the phlebostatic axis will result in pressure readings that are higher than actual readings.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-5

Question 25

Type: MCMA

Which actions are correct when the nurse is performing the Allens test?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Occlude the radial artery and, after 15 seconds, occlude the ulnar artery.

2. Ask the patient to hold the hand below waist level for 30 seconds before beginning the test.

3. Release pressure over the ulnar artery first.

4. Hold pressure on the radial artery for 30 seconds before assessing the hand.

5. Consider color return to the hand in 20 seconds as a negative test.

Correct Answer: 3,5

Rationale 1: The arteries are occluded at the same time.

Rationale 2: The patient should be asked to hold the hand above the head.

Rationale 3: After the patient releases the fist, the nurse releases pressure on the ulnar artery.

Rationale 4: Holding pressure on the radial artery for 30 seconds is not part of the Allens test.

Rationale 5: In this case a negative result indicates the superficial palmar arch is not intact. Color return that takes over 15 seconds is considered a negative result.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-4

Question 26

Type: MCMA

Which actions would the nurse take when removing a radial artery catheter?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Don a sterile gown, sterile gloves, and eye protection.

2. Send the tip of the catheter to the laboratory for culture and sensitivity.

3. Remove the dressing.

4. Apply direct pressure to the insertion site after the catheter is removed.

5. Plan frequent observation of the site after removal of the catheter.

Correct Answer: 3,4,5

Rationale 1: The nurse should wear clean gloves and eye protection. A gown may be worn, but it does not have to be sterile.

Rationale 2: Routine cultures of catheter tips are no longer recommended.

Rationale 3: The nurse must remove the dressing to have adequate visualization of the insertion site.

Rationale 4: Direct pressure is required to support hemostasis.

Rationale 5: The nurse must continue to assess the site for hematoma formation or for frank bleeding after the catheter has been removed.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

Question 27

Type: MCMA

The nurse is assisting with the insertion of a subclavian central venous catheter. Which actions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Place the patient in a prone position.

2. Ask the patient to turn the head away from the insertion site.

3. Alert the patient that the face may be covered temporarily with sterile drapes.

4. Place the bed in Trendelenburg position.

5. Ask the patient to cough when feeling the insertion catheter touch the skin.

Correct Answer: 2,3,4

Rationale 1: Prone positioning will not allow access to the subclavian vein.

Rationale 2: Having the patient turn the head away from the insertion site helps make it easier to visualize the site and also decreases the potential for contamination.

Rationale 3: To create a sterile field, the patients upper torso, including the face, is covered with sterile drapes.

Rationale 4: The Trendelenburg position facilitates dilation of the central veins and reduces the risk of an air embolus.

Rationale 5: The patient should be asked to lie very still during this procedure. Coughing is not indicated.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

Question 28

Type: MCMA

During insertion of a subclavian central venous catheter, the patient reports chest pain. Vital signs reveal hypotension and tachypnea. Upon inspection, the patient appears dyspneic and cyanotic. The nurse would assess for which conditions?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Pneumothorax

2. Air embolism

3. Perforation of the left ventricle

4. Stroke

5. Fluid volume overload

Correct Answer: 1,2

Rationale 1: These assessment findings support the development of a pneumothorax, which is a risk associated with central venous catheter placement.

Rationale 2: These assessment findings support the development of an air embolism, which is a risk associated with central venous catheter placement.

Rationale 3: Perforation of the left ventricle would be an unlikely complication of this procedure.

Rationale 4: These assessment findings would not raise immediate suspicion of stroke. Stroke is not commonly associated with central line placement.

Rationale 5: The patient who has fluid volume overload may not tolerate the positioning necessary for central line placement, but the health care provider would be aware of this issue prior to the procedure. Fluid volume overload is not caused by the placement of a central line.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-4

Question 29

Type: MCSA

Which nursing instruction is given to the patient whose central venous catheter will be removed?

1. Take a deep breath.

2. Roll over to your left side.

3. Use this gauze to apply pressure over the insertion site.

4. Place your hand over your head as I remove this line.

Correct Answer: 1

Rationale 1: The nurse removes the catheter when the patient takes a deep breath to decrease the chances of air embolism.

Rationale 2: There is no reason for the patient to roll to the left side.

Rationale 3: It is the nurses responsibility to apply pressure over the insertion site.

Rationale 4: There is no benefit in the patient placing the hand over the head during removal of a central line.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

Question 30

Type: MCSA

The patient is experiencing premature ventricular contractions (PVCs) every other beat of the cardiac rhythm. The nurse would expect which effect on the patients cardiac output?

1. The cardiac output will be doubled.

2. There will be little if any effect on cardiac output.

3. Cardiac output will be markedly reduced.

4. Cardiac output will be reduced with normal beats and increased with PVCs.

Correct Answer: 3

Rationale 1: The cardiac output is adversely affected by PVCs.

Rationale 2: Frequent PVCs will affect cardiac output.

Rationale 3: The presence of so many PVCs will markedly reduce cardiac output.

Rationale 4: The cardiac output is a measurement over time and is not figured beat by beat. PVCs will reduce cardiac output.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-5

Question 31

Type: MCMA

The patient has been X-rayed after insertion of a pulmonary artery catheter (PAC). Which components of this system would the nurse expect to see in the right atrium?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The proximal port

2. The thermistor

3. The proximal injectate port

4. The transducer

5. The balloon

Correct Answer: 1,3

Rationale 1: The proximal port of the PAC sits in the right atrium and is used to infuse IV fluids and nonvasoactive medications.

Rationale 2: The thermistor is on the tip of the PAC and should be in the pulmonary artery.

Rationale 3: The proximal injectate port is located in the right atrium and is used for measuring cardiac output.

Rationale 4: The transducer is located outside the patients body.

Rationale 5: The balloon is located on the distal end of the PAC, which will be located in the pulmonary artery.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-2

Question 32

Type: MCSA

A critically ill patient is admitted for the treatment of pneumonia and is receiving mechanical ventilation. The central venous pressure (CVP) is 15, and the pulmonary arterial pressure (PAP) is 55/35. What evaluation can the nurse make from this data?

1. Both pressures are low because the patient has increased fluid volume and may be septic from the pneumonia.

2. The CVP is low because the patient has increased fluid volume, and the high PAP indicates increased pressure in the lungs.

3. Both pressures are high, indicating that the patient has increased pressure in the lungs and a high fluid volume.

4. The CVP is high, indicating increased fluid volume, and the low PAP indicates impending heart failure.

Correct Answer: 3

Rationale 1: Both the CVP and the PAP are extremely high.

Rationale 2: Both the CVP and the PAP are extremely high.

Rationale 3: Both the CVP and the PAP are extremely high. The high PAP indicates pressure in the lungs and is partially caused by mechanical ventilation as well as the pneumonia. The high CVP indicates increased fluid volume. The nurse would evaluate for signs of heart failure and renal failure in this critically ill patient.

Rationale 4: Both the CVP and the PAP are extremely high.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-3

Question 33

Type: MCMA

The nurse is obtaining a thermodilution cardiac output measurement from a pulmonary artery catheter (PAC). Which techniques should the nurse use?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Keep the injectate at least 10F below room temperature.

2. Inject the injectate over 3045 seconds.

3. Inject the injectate smoothly.

4. Inject the standard amount of injectate for the brand of catheter.

5. Perform three measurements 1 to 2 minutes apart.

Correct Answer: 3,4,5

Rationale 1: The injectate is kept at room temperature.

Rationale 2: The injectate should be injected in less than 4 seconds.

Rationale 3: The injectate should be injected smoothly.

Rationale 4: Using more or less than the standard amount of injectate will invalidate the measurement.

Rationale 5: The average of three measurements obtained 1 to 2 minutes apart is considered the cardiac output.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 31-4

Question 34

Type: FIB

The nurse would discard any cardiac output measurement obtained from a pulmonary artery catheter if the measurement was questionable based on the curve or if two measurements differed by _____ %.

Standard Text:

Correct Answer: 10

Rationale : Operator variability is an inherent risk of pulmonary artery catheter calculation of cardiac output. The nurse should assess the shape of the cardiac output curve and discard results with a questionable curve. The nurse should also discard any two measurements that vary by 10%.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-4

Question 35

Type: MCMA

Which findings would suggest to the nurse that the balloon of a pulmonary artery catheter (PAC) has ruptured?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. No pulmonary artery occlusion pressure tracing appears when the balloon is inflated.

2. Blood is noted in the air inflation port.

3. It is not possible to pull air back out of the balloon with the syringe.

4. A right bundle branch block appears on the electrocardiogram tracing.

5. The normal pulmonary artery waveform does not return after obtaining the pulmonary artery occlusion pressure.

Correct Answer: 1,2

Rationale 1: If the balloon has ruptured, it will not occlude the artery and no tracing will appear.

Rationale 2: Blood in the inflation port indicates that the balloon has allowed leakage back into the catheter. This would occur if the balloon was not intact.

Rationale 3: The balloon should be allowed to deflate passively. Using the syringe to remove air may cause balloon rupture.

Rationale 4: This conduction defect is more likely to occur if the catheter tip has advanced through the right ventricle.

Rationale 5: If the normal pulmonary artery waveform does not return, it is more likely that the balloon is wedged despite deflation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 31-4

 

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