A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP should the nurse make?
Fluid overload
Intracardiac shunt
Hypovolemia
Left ventricular failure
The Correct Answer is C
Choice A Reason: This is incorrect because fluid overload is a condition of excess fluid volume in the body. A client who has fluid overload is more likely to have a high CVP, which indicates increased pressure in the right atrium and vena cava.
Choice B Reason: This is incorrect because an intracardiac shunt is a condition of abnormal blood flow between the chambers of the heart. A client who has an intracardiac shunt may have a normal or high CVP, depending on the direction and magnitude of the shunt.
Choice C Reason: This is correct because hypovolemia is a condition of low fluid volume in the body. A client who has hypovolemia is more likely to have a low CVP, which indicates decreased pressure in the right atrium and vena cava.
Choice D Reason: This is incorrect because left ventricular failure is a condition of impaired pumping function of the left ventricle. A client who has left ventricular failure may have a normal or high CVP, depending on the degree of backward failure and pulmonary congestion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This choice is incorrect because providing a brightly lit environment may stimulate the client and increase the intracranial pressure. A brightly lit environment is an environment that has a high level of illumination or brightness. It may be used for clients who have depression, seasonal affective disorder, or insomnia, but it does not help to reduce the intracranial pressure.
Choice B Reason: This choice is incorrect because teaching controlled coughing and deep breathing may increase the intrathoracic pressure and increase the intracranial pressure. Controlled coughing and deep breathing are techniques that help to clear the airway and improve lung expansion. They may be used for clients who have respiratory infections, chronic obstructive pulmonary disease, or postoperative complications, but they do not help to reduce the intracranial pressure.
Choice C Reason: This choice is incorrect because encouraging a minimum intake of 2000 mL (67.5 oz) of clear fluids per day may cause fluid overload and increase the intracranial pressure. Fluid overload is a condition in which the body has too much fluid, which can impair the function of the heart, lungs, and kidneys. Therefore, restricting fluid intake and using diuretics may be indicated for clients who have increased intracranial pressure.
Choice D Reason: This choice is correct because elevating the head of the bed 20° may help to improve the venous drainage and decrease the intracranial pressure. As explained above, positioning the client in a semi-Fowler's or high-Fowler's position can facilitate breathing and prevent further complications. However, elevating the head of the bed more than 30° may decrease the cerebral perfusion pressure (CPP), which is the difference between the mean arterial pressure (MAP) and the intracranial pressure (ICP). A normal CPP range is 70 to 100 mm Hg, and a low CPP (<50 mm Hg) can cause cerebral ischemia, herniation, or death. Therefore, elevating the head of the bed to a moderate angle (20°) may be optimal for clients who have increased ICP.
Correct Answer is A
Explanation
Choice A Reason: Packed RBCs are indicated for clients who have hypovolemic shock due to blood loss, as they increase the oxygen-carrying capacity of the blood and restore the blood volume.
Choice B Reason: Cryoprecipitates are indicated for clients who have hemophilia or von Willebrand disease, as they contain clotting factors that help stop bleeding.
Choice C Reason: Albumin is indicated for clients who have hypovolemic shock due to fluid loss, such as from burns or ascites, as it increases the plasma oncotic pressure and draws fluid into the vascular space.
Choice D Reason: Platelets are indicated for clients who have thrombocytopenia or platelet dysfunction, as they help prevent or control bleeding.
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