The nurse is evaluating a client's central venous pressure (CVP) also called right atrial pressure (RAP) readings that are trending upwards. Which nursing problem is supported by the pathophysiologic mechanism most likely causing the increases?

Decreased cardiac output.

Ineffective airway clearance.

Ineffective peripheral tissue perfusion.

Deficient fluid volume.

Answer and Explanation

The Correct Answer is A

A. Decreased cardiac output. Central venous pressure (CVP), also called right atrial pressure (RAP), reflects right ventricular preload and overall fluid status. An increasing CVP indicates fluid overload or impaired right ventricular function, both of which can lead to decreased cardiac output. Conditions such as right heart failure, pulmonary hypertension, or excessive fluid resuscitation can cause elevated CVP, reducing the heart’s ability to pump effectively and leading to poor systemic circulation.
B. Ineffective airway clearance. Airway clearance is not directly related to CVP measurements. While severe pulmonary conditions like ARDS or COPD can contribute to cardiac strain and right heart failure, the primary mechanism for rising CVP is cardiac dysfunction or fluid overload, not airway obstruction.
C. Ineffective peripheral tissue perfusion. Although decreased cardiac output can impair tissue perfusion, this choice is too broad. Increased CVP specifically reflects right-sided heart function and preload, making decreased cardiac output the more precise diagnosis related to the pathophysiologic mechanism.
D. Deficient fluid volume. A low CVP is associated with hypovolemia and fluid deficits, while an increasing CVP suggests fluid overload, heart failure, or venous congestion. Deficient fluid volume would cause a downward trend in CVP, not an increase.

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Correct Answer is C

Explanation

A. Suture removal kit. A suture removal kit is used when the chest tube is ready for removal, but it is not necessary to keep at the bedside during routine chest tube management. The priority is ensuring emergency supplies are available if the tube becomes dislodged.
B. Suction catheter. A suction catheter is used to remove secretions from the airway but is not essential for managing a chest tube. Chest drainage systems function independently to remove air or fluid, and routine suctioning is not required for chest tube management.
C. Sterile gauze dressing. If the chest tube accidentally dislodges, an occlusive dressing (such as sterile gauze with petroleum jelly) should be applied immediately to prevent air from re-entering the pleural space, which could lead to a tension pneumothorax. Keeping sterile gauze at the bedside ensures rapid intervention in case of accidental chest tube removal.
D. Sterile piston syringe. A sterile piston syringe is used for irrigating wounds or suctioning secretions, but it is not necessary for chest tube management. The closed drainage system should never be manually flushed unless specifically ordered by a healthcare provider.

A. Insert a large bore peripheral IV catheter. B. Raise extremity above the heart. C. Tighten the cloth around the leg. D. Apply ice over the bite mark.

Correct Answer is A

Explanation

A. Insert a large bore peripheral IV catheter. The client is showing signs of shock (tachycardia, hypotension, tachypnea) likely due to envenomation and systemic venom effects. Rapid IV access is essential for fluid resuscitation, administration of antivenom, and management of shock. A large bore (18-gauge or larger) IV catheter allows for aggressive fluid therapy to maintain perfusion and prevent circulatory collapse.
B. Raise extremity above the heart. Elevating the limb can increase venom circulation, worsening systemic effects. Instead, the affected extremity should be kept at heart level to slow venom spread while ensuring adequate perfusion.
C. Tighten the cloth around the leg. Further tightening the makeshift tourniquet can lead to vascular compromise, ischemia, and increased local tissue damage. Modern guidelines discourage tourniquets as they do not prevent venom spread effectively and may worsen outcomes. The best approach is to loosen or remove restrictive bindings and keep the limb immobilized at heart level.
D. Apply ice over the bite mark. Cold therapy is contraindicated as it can worsen tissue damage by causing vasoconstriction, trapping venom, and increasing necrosis. Instead, the priority is IV access, fluid resuscitation, and preparing for possible antivenom administration.

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The nurse is evaluating a client's central venous pressure (CVP) also called right atrial pressure (RAP) readings that are trending upwards. Which nursing problem is supported by the pathophysiologic mechanism most likely causing the increases?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has a chest tube connected to a closed water-seal drainage system with suction. Which equipment should the nurse always have available at the client's bedside?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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