Chapter 7 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 7

Question 1

Type: MCSA

The nurse is preparing to use a patients pulmonary artery catheter to obtain hemodynamic measurements. Which nursing action is indicated?

1. Zero the transducer at the phlebostatic axis.

2. Place the patient in Trendelenburg position.

3. Warm cardiac output injectate fluid to body temperature.

4. Prepare 20 mL of injectate.

Correct Answer: 1

Rationale 1: The phlebostatic axis approximates the level of the right atrium and is considered to represent the level of the catheter tip.

Rationale 2: Trendelenburg position or the head down position may be used during insertion of the catheter to make visualization of the jugular approach easier. However, supine is the recommended position for hemodynamic readings.

Rationale 3: Injectate should be iced or room temperature but not warmed.

Rationale 4: The traditional method of thermodilution cardiac output uses a 10mL bolus of injectate.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-4

Question 2

Type: MCSA

The preceptor nurse is assisting a newly hired nurse with completion of hemodynamic assessment using a pulmonary artery catheter. Which action would require the preceptor to intervene?

1. Inflating the pressure bag to 300 mm Hg

2. Infusing a vasoactive drug through the proximal injectate port

3. Obtaining a pulmonary artery wedge pressure reading through the distal port

4. Using iced normal saline to obtain a cardiac output

Correct Answer: 2

Rationale 1: In order to overcome arterial pressure and prevent blood from backing up into the pressure tubing, the pressure bag placed around the flush solution should be inflated to 300 mm Hg.

Rationale 2: The proximal injectate port is the primary port used for obtaining cardiac output via boluses of iced or room temperature normal saline. Because of the risk of inadvertent bolus of potent medications, neither vasopressor nor vasodilators should be administered through the same port used for obtaining cardiac output. It would be safer to infuse vasoactive drugs through the proximal infusion port.

Rationale 3: The distal port is the designated port for continuous monitoring of the pulmonary artery pressure and for obtaining the pulmonary artery wedge pressure.

Rationale 4: Either iced or room temperature normal saline can effectively be used to obtain accurate cardiac output measurements.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 7-3

Question 3

Type: MCSA

While caring for a patient being hemodynamically monitored the nurse notices that the systemic vascular resistance has risen to 1,800 dynes/sec/cm5, whereas the patients cardiac output remains at 6.0 liters per minute. What would the nurse expect the patients blood pressure to be?

1. Increased

2. Unchanged

3. Decreased

4. Initially decreased, and then increased

Correct Answer: 1

Rationale 1: Systemic vascular resistance or afterload is the pressure the heart pumps against to get volume out to the lungs or the body. If that pressure is increased, but volume, measured by cardiac output stays the same, it means that the heart is working harder to get volume out and the blood pressure will go up.

Rationale 2: Increasing systemic vascular resistance with no change in cardiac output does indicate a change in blood pressure.

Rationale 3: Since the heart is working harder, blood pressure will not decrease immediately.

Rationale 4: The blood pressure would increase initially in response to the increased workload. If treatment is not initiated, the heart will eventually tire, and a decrease in blood pressure could be expected.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-7

Question 4

Type: MCSA

The nurse is reviewing the results of a patients cardiac output curve and notes that the size of the curve is small. Which of the following does this finding indicate?

1. A low cardiac output

2. Poor injection technique

3. Incorrect placement of the catheter

4. A high cardiac output

Correct Answer: 4

Rationale 1: A large curve indicates a slow return to baseline temperature and, therefore, a low cardiac output.

Rationale 2: The size of the curve does not indicate poor injection technique.

Rationale 3: A small cardiac output curve does not indicate incorrect placement of the catheter.

Rationale 4: A small curve indicates a rapid return of the blood to its baseline temperature and, therefore, a high cardiac output.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-3

Question 5

Type: MCMA

The nurse is performing an assessment on a patient whose right atrial pressure is 12 mm Hg. Which findings would the nurse anticipate?

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

Standard Text: Select all that apply.

1. Jugular vein distention

2. Weak, thready pulse

3. Presence of rales and rhonchi

4. Poor skin turgor

5. Hepatomegaly

Correct Answer: 1,5

Rationale 1: Elevation of right arterial pressure indicates high right ventricular preload which results in fluid back up into the venous system. Jugular vein distention is a sign of increased right ventricular preload.

Rationale 2: The pulse is usually full and bounding when right atrial pressure is increased.

Rationale 3: Rales and rhonchi are signs of left-sided heart failure.

Rationale 4: Skin turgor is a manifestation of hydration status.

Rationale 5: Elevation of right arterial pressure indicates high right ventricular preload, which results in fluid back up into the venous system. Hepatomegaly is a sign of increased right ventricular preload.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-5

Question 6

Type: MCMA

A patient who was stabbed multiple times in the chest and abdomen has just returned from emergency surgery. Hemodynamic monitoring was initiated during surgery and now reveals that the patients right atrial pressure has dropped to 2 mmHg. The nurse would assess for findings of 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. Internal hemorrhage

2. Fluid loss during surgery

3. Vasodilation from drugs administered during surgery

4. Left heart failure

5. Cardiac tamponade

Correct Answer: 1,2,3

Rationale 1: Hemorrhage is a cause of absolute fluid deficit and will be reflected in a low right atrial pressure.

Rationale 2: If the patient lost a significant amount of blood or other fluids during surgery the right atrial pressure could drop.

Rationale 3: Vasodilation reduces venous return to the right atrium, resulting in decrease of right atrial pressure.

Rationale 4: Left heart failure results in an increased volume in the pulmonary circulation which increases right atrial pressure.

Rationale 5: Cardiac tamponade or rapid fluid buildup in the pericardial space increases pressures on the heart and would result in increased right atrial pressure.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-5

Question 7

Type: MCSA

While evaluating a patients pulmonary artery waveforms, the nurse notes a sudden onset of right ventricular waves. Which nursing intervention is indicated?

1. Assist the patient to a left side-lying position.

2. Notify the physician for repositioning.

3. Increase intravenous fluids.

4. Nothing, since this is an expected occurrence.

Correct Answer: 2

Rationale 1: Assisting the patient to a left side-lying position is not going to reposition the catheter.

Rationale 2: The right ventricular waveform will appear when the catheter tip retreats from the pulmonary artery into the right ventricle. Should the waveform appear, as in the case with the patient, the nurse should notify the physician for repositioning.

Rationale 3: There is nothing to indicate that the patient needs an increase in intravenous fluids.

Rationale 4: This is not an expected occurrence and should not be ignored.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-4

Question 8

Type: MCSA

A patient with congestive heart failure is receiving scheduled doses of an intravenous diuretic. After administering the drug, which finding would indicate to the nurse that the drug was effective?

1. A pulmonary artery wedge pressure of 16 mm Hg

2. Pulmonary artery pressure of 34/16 mm Hg

3. Systemic vascular resistance of 1,400 dynes/sec/cm-5

4. A right atrial pressure of 5 mm Hg

Correct Answer: 4

Rationale 1: Normal pulmonary arterial wedge pressure is 4 to 12; 16 is high and would indicate high preload.

Rationale 2: Normal pulmonary artery pressure is 20 to 30 mm Hg/8 to 15 mm Hg. These pressures should decrease with diuretic administration.

Rationale 3: Normal systemic vascular resistance is 800 to 1,200 dynes/sec/cm-5. With diuretic use, the systemic vascular resistance should also normalize.

Rationale 4: A right atrial pressure of 5 is a normal reading and would indicate the diuretic is having its intended effect.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-6

Question 9

Type: MCSA

The nurse is caring for a patient who is being monitored with a pulmonary artery catheter. Which change requires immediate intervention?

1. Systemic vascular resistance of 900 dynes/sec/cm5

2. Appearance of an a wave on the pulmonary artery waveform

3. Pulmonary artery wedge pressure of 10 mm Hg

4. Spontaneous development of a pulmonary artery wedge pressure waveform

Correct Answer: 4

Rationale 1: A systemic vascular resistance of 900 is normal.

Rationale 2: The a wave is indicative of the rise in atrial pressure produced by left atrial contraction and is normal.

Rationale 3: A pulmonary arterial wedge pressure of 10 mm Hg is within normal limits.

Rationale 4: A permanent wedge waveform is an indication of catheter migration further into the pulmonary artery causing occlusion. Immediate intervention is needed to prevent pulmonary infarction.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-6

Question 10

Type: MCSA

A patient is admitted for evaluation of hypotension. Which assessment by the nurse would require immediate attention?

1. Pulmonary artery wedge pressure of 2 mm Hg

2. Heart rate of 112

3. Urine output of 25 mL/hr

4. Presence of rales at both lung bases

Correct Answer: 1

Rationale 1: The normal pulmonary artery wedge pressure is 4 to 12 mm Hg. A wedge pressure of 2 mm Hg is indicative of significant hypovolemia. Additional assessment is critical.

Rationale 2: Although a heart rate of 112 is abnormal it is not the most significant of the findings provided.

Rationale 3: Urine output of 25 mL/hr is low to low normal, but is not the most significant finding provided.

Rationale 4: Rales at lung bases are an abnormal finding, but unless the patient has significant respiratory distress, they would not require immediate intervention. This is not the most significant finding provided.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6-3

Question 11

Type: MCMA

Which nursing interventions are indicated when measuring pulmonary artery wedge pressure (PAWP)?

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

Standard Text: Select all that apply.

1. Use no more than 1.25 mL of air to inflate the balloon.

2. Pull back on the syringe to deflate the balloon.

3. Leave the balloon slightly inflated to maintain integrity.

4. Maintain balloon inflation for 3 to 5 minutes to obtain a stable reading.

5. If there is any resistance during inflation do not continue.

Correct Answer: 1,5

Rationale 1: Using the smallest inflation volume possible, typically less than 1.25 mL, reduces the risk of balloon rupture.

Rationale 2: Passive deflation should be used to avoid damage to the balloon.

Rationale 3: The balloon should be completely deflated to avoid a continuous wedge, which could lead to pulmonary infarction.

Rationale 4: The balloon should be inflated only long enough to obtain a stable reading.

Rationale 5: Resistance may indicate that the balloon is compromising the artery. The nurse should stop inflation, allow the balloon to passively deflate and call the health care provider.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-6

Question 12

Type: MCSA

The nurse is caring for a patient whose pulmonary artery wedge pressure is 16 mm Hg. The patients neck veins are flat, lungs are clear, and the pulse pressure is low. Which intervention would the nurse anticipate?

1. Administer a 500 mL normal saline fluid bolus.

2. Repeat the reading after recalibrating the system.

3. Repeat the reading after repositioning the patient.

4. Administer a diuretic and a vasodilator.

Correct Answer: 4

Rationale 1: Administering a 500 mL normal saline fluid bolus would be expected if preload were low.

Rationale 2: The assessment findings presented match the PAWP reading, so no repeat of the measurement is necessary.

Rationale 3: The patient should be placed in the supine position whenever completing a hemodynamic assessment. Repositioning the patient is unlikely to affect the reading.

Rationale 4: The normal pulmonary artery wedge pressure is 4 to 12 mm Hg. A reading of 16 mm Hg indicates high preload, and the nurse can anticipate administering a diuretic and a vasodilator to help reduce preload.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-6

Question 13

Type: MCSA

A patient who has a radial artery catheter in place is complaining of numbness and tingling in the fingers. What is the nurses priority assessment?

1. Is there a palpable pulse?

2. Is blood is easily obtained from the catheter?

3. Does the patient have a fever?

4. Does the waveform have a characteristic appearance?

Correct Answer: 1

Rationale 1: Monitoring circulation distal to the arterial insertion site is the priority nursing function. Skin color and temperature and all pulses should be regularly assessed and documented.

Rationale 2: It is important to be able to easily access blood from the catheter, but this is not the priority assessment.

Rationale 3: Fever might indicate an infection at the insertion site, but if this is occurring it will take time to treat. This is a very important assessment, but is not the highest priority.

Rationale 4: An appropriate and normal waveform is an assurance that the system is functioning and measurements would be accurate. However, this is not the most important for the patients safety and prevention of complications.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-2

Question 14

Type: MCMA

The nurse is assessing a patients arterial waveform and notes a notch on the descending portion of the waveform. The nurse associates this notch with which physiological events?

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

Standard Text: Select all that apply.

1. Closure of the aortic valve

2. The highest systolic pressure

3. Systolic ejection of blood

4. The diastolic pressure

5. Beginning of ventricular diastole

Correct Answer: 1,5

Rationale 1: This dicrotic notch represents closure of the aortic valve.

Rationale 2: When the aortic valve opens, blood is ejected into the aorta. This forms a steep upstroke on the arterial waveform, called the anacrotic limb. The top of this limb represents the peak, or highest systolic pressure.

Rationale 3: After the waveform reaches its peak, it begins to descend. This descent forms the dicrotic limb and represents systolic ejection of blood that is continuing at a reduced force.

Rationale 4: The lowest portion of the waveform represents the diastolic pressure and is reflected digitally on the monitor.

Rationale 5: This dicrotic notch represents the beginning of ventricular diastole.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-2

Question 15

Type: MCSA

A patient who has a pulmonary artery catheter in place is to receive the drug nitroprusside. The nurse would assess for which indicator of the drugs effectiveness?

1. Decreased systemic vascular resistance

2. Decreased cardiac output

3. Increased right atrial pressure

4. Increased pulmonary artery wedge pressure

Correct Answer: 1

Rationale 1: Nitroprusside is a potent systemic vasodilator with primary action on decreasing afterload, which is measured by systemic vascular resistance.

Rationale 2: Nitroprusside should decrease cardiac workload and increase stroke volume which will increase cardiac output.

Rationale 3: Nitroprusside administration should result in right atrial pressure decrease.

Rationale 4: Pulmonary artery wedge pressure should decrease.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-7

Question 16

Type: MCSA

The nurse is caring for a patient with sepsis. On completing the hemodynamic assessment the nurse notes that the patients afterload, measured by the systemic vascular resistance, is 400 dynes/sec/cm-5. The nurse evaluates this finding to be primarily the result of which change associated with sepsis?

1. Decreased circulating volume

2. Reaction to antibiotics used to treat sepsis

3. Marked vasodilation

4. Decreased ventricular contractility

Correct Answer: 3

Rationale 1: Hemodynamic changes associated with sepsis are not caused by low circulating volume.

Rationale 2: The primary reason for decreased vascular resistance is not related to reaction to medications.

Rationale 3: Sepsis, through its release of inflammatory mediators, causes vasodilation, resulting in the markedly low systemic vascular resistance.

Rationale 4: Ventricular contractility may be reduced following the release of myocardial depressant factor as a result of sepsis. However, this is not the primary cause of decreased vascular resistance.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-7

Question 17

Type: MCSA

A patient is being prepared for impedance cardiography. Which information will the nurse provide?

1. This technology will use ultrasound to measure your heart rate and blood flow.

2. We are preparing to measure the oxygenation of your peripheral tissues.

3. A catheter will be inserted into a vein in your neck.

4. Electrodes will be placed on your neck and your lateral chest.

Correct Answer: 4

Rationale 1: Doppler technology uses ultrasound through a probe to measure heart rate and blood flow.

Rationale 2: Pulse oximetry is used to measure peripheral oxygenation of tissues.

Rationale 3: Cannulation of the right subclavian or internal jugular vein is necessary for placement of a central venous catheter.

Rationale 4: Impedance cardiography is used to assess cardiac function through the use of a high-frequency, low-amplitude current to measure the resistance to flow of the electrical current. The procedure includes placing electrodes bilaterally at the base of the neck and on the lateral chest at the level of the diaphragm.

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: 7-2

Question 18

Type: MCSA

A patient is admitted to the emergency department after fainting. Vital signs are blood pressure 86/60, heart rate 160 bpm, and respirations 20. The patients skin is cool to the touch. Which nursing diagnosis (NDX) is priority?

1. Risk for Falls

2. Fluid Volume Deficient

3. Decreased Cardiac Output

4. Impaired Gas Exchange

Correct Answer: 3

Rationale 1: This patient does have risk for injury from falling, but this NDX is not the current priority. Interventions to reverse the primary NDX will help to reduce this risk.

Rationale 2: Hypovolemia may result in syncope, but there is not enough information to evaluate whether this is occurring with this patient.

Rationale 3: Loss of consciousness, cool skin, low blood pressure, and increased heart rate all indicate decreased cardiac output. Tachycardia can result in decreased cardiac output by shortening ventricular filling time during diastole.

Rationale 4: The scenario does not present arterial blood gases, so a diagnosis of impaired gas exchange is not supported.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 7-1

Question 19

Type: MCMA

Which nursing actions are necessary to collect information needed to figure the patients cardiac index?

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

Standard Text: Select all that apply.

1. Weigh the patient.

2. Take the patients temperature.

3. Measure the patients blood pressure.

4. Measure the patients height.

5. Determine the patients age.

Correct Answer: 1,4

Rationale 1: Calculating cardiac index requires knowledge of the patients weight.

Rationale 2: Body temperature is not used to figure cardiac index.

Rationale 3: Blood pressure is not used to figure cardiac index.

Rationale 4: In order to figure the cardiac index, the nurse must know that patients height.

Rationale 5: It is not necessary to know the patients age in order to determine cardiac index.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7-1

Question 20

Type: MCSA

A patient requires insertion of a pulmonary artery catheter. Which nursing action is indicated?

1. Instill air in all stopcocks.

2. Prime the pressure monitoring system.

3. Call for the rapid response team.

4. Obtain sterile gowns, gloves, caps, and masks for all persons who will be present during the insertion.

Correct Answer: 2

Rationale 1: Air should be removed from all stopcocks.

Rationale 2: The pressure monitoring system should be primed to remove all air.

Rationale 3: There is no need for rapid response team intervention.

Rationale 4: The people inserting the catheter will wear sterile gowns, gloves, caps, and masks. Others in the room should wear a cap and mask.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7-4

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

Leave a Reply