The nurse is collecting a blood sample for a mixed venous oxygen saturation (SVO2) level from the distal lumen of a pulmonary artery (PA) catheter of a client in cardiogenic shock. Which action should the nurse implement?
Expel the excess air and heparin from the syringe.
Place sample in arterial blood gas syringe.
Obtain a minimum of 1 mL of blood.
Aspirate the blood sample slowly.
The Correct Answer is C
A. Expel the excess air and heparin from the syringe. While removing excess air prevents gas exchange alterations, this is not the priority when obtaining an SVO₂ sample. Excess heparin could dilute the sample, but proper blood volume collection is the first concern.
B. Place sample in arterial blood gas syringe. SVO₂ measures venous oxygen saturation, which is different from arterial blood gases (ABGs). Using an ABG syringe is incorrect because it is heparinized for arterial sampling, and arterial blood does not reflect mixed venous oxygenation.
C. Obtain a minimum of 1 mL of blood. SVO₂ is measured from the distal lumen of a pulmonary artery (PA) catheter to assess oxygen delivery and consumption. At least 1 mL of blood is required for an accurate reading, ensuring sufficient sample volume for laboratory analysis.
D. Aspirate the blood sample slowly. While slow aspiration can help prevent hemolysis, it is not the primary concern when collecting an SVO₂ sample. The priority is obtaining a sufficient volume (≥1 mL) for an accurate measurement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Narrowed pulse pressure, presence of 3+ femoral pulses, apneic episodes. Narrowed pulse pressure is consistent with hypovolemic shock, but 3+ femoral pulses are not expected, as shock leads to weak, thready pulses due to reduced perfusion. Apneic episodes typically occur in the late stages of shock, not in the early or progressive stages.
B. Widening pulse pressure, muffled heart sounds, presence of atrial gallop. A widening pulse pressure and muffled heart sounds are more indicative of cardiac tamponade, not hypovolemic shock. Hypovolemic shock is characterized by a narrowing pulse pressure due to a drop in systolic blood pressure while diastolic pressure remains relatively stable.
C. Increased heart rate, lowered systolic reading, peripheral extremity mottling. Tachycardia is an early compensatory response to hypovolemia as the body attempts to maintain cardiac output. As shock progresses, systolic blood pressure drops due to inadequate circulating volume. Peripheral extremity mottling occurs as the body shunts blood to vital organs, reducing perfusion to the skin. These signs are characteristic of progressive hypovolemic shock.
D. Irregular heart rate, elevated diastolic reading, increased respiratory rate. An irregular heart rate is not a primary indicator of hypovolemic shock. While respiratory rate increases in response to decreased oxygen delivery, an elevated diastolic reading is uncommon, as diastolic pressure tends to stay stable or decrease slightly with ongoing hypovolemia.
Correct Answer is D
Explanation
A. Prepare to give phenytoin IV as prescribed. Phenytoin is used for seizure prophylaxis in clients with moderate to severe head injuries (GCS ≤ 8–10). A GCS score of 14 indicates mild head injury, and prophylactic anticonvulsants may not be necessary unless ordered for specific risk factors.
B. Perform a substernal rub to evoke a response to pain. A substernal rub (painful stimulus) is used to assess response in unconscious or unresponsive clients (GCS ≤ 8). With a GCS of 14, the client is alert or nearly fully conscious, making a painful stimulus unnecessary and inappropriate.
C. Promptly notify the healthcare provider (HCP) of the GCS score. A GCS of 14 is not a critical or emergency finding, as it indicates mild neurological impairment. While the HCP should be updated on significant changes, routine monitoring is sufficient unless deterioration occurs.
D. Continue monitoring the client's GCS score every 2 hours. Frequent neurological assessments are crucial in head injury management to detect worsening conditions like increasing intracranial pressure (ICP) or cerebral edema. Monitoring the GCS every 2 hours ensures timely intervention if the client’s condition changes.
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