The nurse is monitoring the central venous pressure (CVP) of a patient with heart failure. The nurse observes that the reading is 12 mmHg. What is the nurse's best action?

Call the provider to report that the reading is low and the patient needs 0.9% sodium chloride

Document the finding as within normal limits

Call the provider to report that the reading is high and the patient may need a furosemide

Document the finding as abnormal

Answer and Explanation

The Correct Answer is C

A. Call the provider to report that the reading is low and the patient needs 0.9% sodium chloride: A CVP of 12 mmHg is elevated, not low. Administering IV fluids in this situation could worsen fluid overload and exacerbate heart failure, making this action inappropriate.

B. Document the finding as within normal limits: Normal CVP ranges from 2–8 mmHg. A reading of 12 mmHg exceeds this range, indicating elevated right atrial pressure and potential fluid overload. Documentation without intervention would miss a critical opportunity to prevent complications.

C. Call the provider to report that the reading is high and the patient may need a furosemide: Elevated CVP suggests volume overload and increased right heart filling pressures. Reporting this finding allows the provider to evaluate the patient for interventions such as diuretics (e.g., furosemide) to reduce preload and manage congestive symptoms, which is the appropriate clinical action.

D. Document the finding as abnormal: While documentation is important, it is insufficient as a standalone action in the context of heart failure. Elevated CVP requires timely clinical assessment and provider notification to prevent worsening pulmonary congestion or systemic fluid overload.

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Correct Answer is B

Explanation

A. Increase the rate of the propofol infusion: Increasing the propofol rate would deepen sedation, which is the opposite of the goal for a spontaneous awakening trial (SAT). Over-sedation can suppress respiratory drive and prevent accurate assessment of the patient’s ability to breathe independently.

B. Decrease the rate of the propofol infusion: The first step before a SAT is to reduce the sedative infusion to allow the patient to awaken safely. Decreasing propofol gradually helps assess neurological status, responsiveness, and readiness to tolerate ventilator weaning while minimizing the risk of agitation or hemodynamic instability.

C. Keep the propofol rate the same: Maintaining the current sedation level would prevent the patient from awakening for assessment. This delays evaluation of readiness for extubation and prolongs mechanical ventilation unnecessarily.

D. Stop propofol and start dexmedetomidine: Switching sedatives is not the initial action for a spontaneous awakening trial. The priority is to reduce sedation gradually to assess the patient’s neurological and respiratory status, not to change agents, which could introduce new pharmacologic effects and complicate monitoring.

A. Eating a diet high in saturated fats B. Regular exercise and physical activity C. Maintaining a healthy weight D. Limiting fluid intake E. Avoiding smoking and tobacco use

Correct Answer is ["B","C","E"]

Explanation

A. Eating a diet high in saturated fats: Diets high in saturated fats contribute to atherosclerosis and cardiovascular disease but do not directly prevent deep vein thrombosis (DVT) or pulmonary embolism. Emphasis should be on heart-healthy diets rather than high saturated fat intake.

B. Regular exercise and physical activity: Physical activity promotes venous return from the lower extremities and reduces blood stasis, which is a major risk factor for DVT. Encouraging regular movement is a key strategy in preventing both DVT and subsequent pulmonary embolism.

C. Maintaining a healthy weight: Obesity increases the risk of venous thromboembolism due to venous stasis and inflammation. Maintaining a healthy weight lowers this risk and supports overall cardiovascular health.

D. Limiting fluid intake: Limiting fluids can increase blood viscosity, promoting stasis and clot formation. Adequate hydration is important in reducing the risk of DVT and PE, so fluid restriction is not recommended for prevention.

E. Avoiding smoking and tobacco use: Smoking damages vascular endothelium, promotes platelet aggregation, and increases coagulability, all of which heighten the risk for DVT and PE. Avoiding tobacco use is an important preventive measure.

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The nurse is monitoring the central venous pressure (CVP) of a patient with heart failure. The nurse observes that the reading is 12 mmHg. What is the nurse's best action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client in the ICU who is receiving a propofol infusion is being prepared for a ventilator weaning trial. What is the nurse's first response to managing the propofol drip before the spontaneous awakening trial?

Correct Answer is B

Explanation

Correct Answer is ["B","C","E"]

Explanation

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