The nurse is caring for a client with a central venous pressure (CVP) monitoring line and is assessing right ventricular function and venous blood return. The results show a decreased central venous pressure. How does the nurse interpret the findings?
Possible hypovolemia.
Right ventricular failure.
Possible hypervolemia.
Left ventricular failure.
The Correct Answer is A
A. Possible hypovolemia: A decreased CVP indicates reduced pressure in the right atrium and central veins, often reflecting a low circulating blood volume. Causes can include hemorrhage, dehydration, or excessive diuretic use. This finding suggests the right ventricle is receiving less venous return, which can compromise cardiac output if not corrected.
B. Right ventricular failure: Right ventricular failure typically results in elevated CVP due to impaired emptying of the right ventricle and venous congestion. A decreased CVP is inconsistent with right ventricular failure, as the pressure in the central veins would be increased rather than reduced.
C. Possible hypervolemia: Hypervolemia is characterized by increased circulating blood volume, which raises venous return and CVP. A decreased CVP suggests the opposite condition, indicating low intravascular volume rather than excess fluid.
D. Left ventricular failure: Left ventricular failure leads to pulmonary congestion and increased pulmonary venous pressure, which may eventually raise right-sided pressures, resulting in elevated CVP. A decreased CVP does not indicate left ventricular failure and suggests the right side is underfilled rather than overloaded.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A client who underwent coronary angioplasty yesterday who is requesting to sit in the bedside chair: Sitting in a chair is a routine activity and does not indicate an immediate change in clinical status. While safety and mobility should be assessed, this client is stable and does not require immediate priority over acute symptoms.
B. A client with dilated cardiomyopathy who developed dyspnea and agitation 1 hour prior to shift change: Dyspnea and agitation are signs of possible acute decompensated heart failure, hypoxia, or pulmonary edema. These symptoms indicate a potentially life-threatening change in condition and require immediate assessment to ensure airway, breathing, and hemodynamic stability. This client has the highest priority.
C. A client who is two days postoperative coronary artery bypass grafting and has a temperature of 100.6°F: A mild postoperative fever is relatively common and may reflect normal inflammatory response. While it should be monitored, it is not immediately life-threatening and is lower priority compared with acute respiratory distress.
D. A client with mitral valve stenosis who is scheduled for a balloon valvuloplasty later today: Preoperative assessment and preparation are important, but unless the client is unstable, this is not as urgent as new-onset dyspnea and agitation. Preprocedure evaluation can be addressed after assessing acute changes in other clients.
Correct Answer is ["A","D","E","F"]
Explanation
A. Skin petechiae: Small, pinpoint red or purple lesions on the skin, known as petechiae, are caused by embolic phenomena from vegetations on the heart valves. They are a classic peripheral manifestation of infective endocarditis and support the diagnosis.
B. Friction rub heart sounds: A friction rub is associated with pericarditis, not endocarditis. It occurs when the pericardial layers rub against each other and is not a typical finding in infective endocarditis.
C. Hypothermia: Infective endocarditis generally presents with fever due to systemic infection. Hypothermia is uncommon and would suggest another underlying condition rather than supporting endocarditis.
D. Fever: Fever is the most common systemic manifestation of infective endocarditis. It results from the body’s inflammatory response to bacterial infection of the endocardial surfaces. Persistent or intermittent fevers are characteristic of this condition.
E. New onset murmur: The development of a new heart murmur indicates valve damage or regurgitation caused by vegetations on the heart valves. This is a cardinal cardiovascular sign of infective endocarditis.
F. Splinter hemorrhages on fingernails: Linear, reddish-brown lesions under the fingernails are caused by small emboli from valvular vegetations. Splinter hemorrhages are a classic peripheral sign supporting the diagnosis of infective endocarditis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.