What is the most immediate action for a nurse to take when hemodynamic monitoring indicates a client in shock has a sudden drop in pulmonary artery pressure?
Check for catheter dislodgment or malfunction.
Secure Adequate venous access for potential fluid administration:
Increase IV fluid infusion rate.
Notify the physician immediately.
The Correct Answer is A
A. Check for catheter dislodgment or malfunction: A sudden drop in pulmonary artery pressure (PAP) may result from technical issues, such as catheter migration, kinking, or transducer misalignment. Confirming the integrity and proper placement of the catheter ensures that readings are accurate before initiating interventions, preventing unnecessary or potentially harmful treatments.
B. Secure adequate venous access for potential fluid administration: While establishing IV access is important for fluid resuscitation in shock, the immediate priority is to verify that the PAP reading is reliable. Acting on potentially erroneous data could lead to fluid overload or other complications.
C. Increase IV fluid infusion rate: Rapid fluid administration may be necessary if the patient is truly hypovolemic, but doing so before confirming accurate hemodynamic data risks overcorrection and adverse effects. Verification of the reading must precede therapeutic interventions.
D. Notify the physician immediately: Physician notification is important once the nurse has validated the PAP reading and assessed the patient’s overall condition. Immediate action should focus first on ensuring that the data accurately reflect the patient’s hemodynamic status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Potassium replacement: Potassium replacement is essential in diabetic ketoacidosis (DKA) because insulin therapy drives potassium into cells, potentially causing hypokalemia. However, potassium correction is secondary; if the patient is severely dehydrated or hypotensive, fluid resuscitation takes priority to restore perfusion before potassium administration.
B. Dextrose infusion: Dextrose infusion is indicated later in DKA management when blood glucose drops to prevent hypoglycemia during insulin therapy. At a blood glucose of 540 mg/dL, dextrose is not indicated and would worsen hyperglycemia if given initially.
C. Fluid resuscitation: The patient presents with hyperglycemia, nausea, vomiting, and fruity breath, consistent with DKA. Hyperglycemia causes osmotic diuresis, leading to severe dehydration and hypovolemia. Restoring intravascular volume with isotonic fluids is the priority intervention to improve perfusion, prevent shock, and facilitate subsequent insulin therapy.
D. Insulin SQ: Insulin therapy is critical for correcting hyperglycemia and ketoacidosis. However, administering insulin before correcting volume depletion can worsen hypotension and compromise renal perfusion. Fluid resuscitation must precede insulin in the initial management of DKA.
Correct Answer is A
Explanation
A. Serum potassium 6.5 mEq/L: Hyperkalemia is a life-threatening electrolyte imbalance commonly seen in burn patients due to cellular destruction and release of intracellular potassium. A potassium level of 6.5 mEq/L can precipitate dangerous cardiac dysrhythmias, including ventricular fibrillation or asystole. Immediate nursing interventions include cardiac monitoring, notifying the healthcare provider, and preparing for treatments.
B. Hematocrit 52%: Elevated hematocrit reflects hemoconcentration, which is common in burn patients due to fluid shifts and plasma loss. While it indicates dehydration and ongoing fluid resuscitation needs, it is not immediately life-threatening and can be addressed with continued monitoring and IV fluids.
C. Serum sodium 146 mEq/L: A sodium level slightly above normal indicates mild hypernatremia, which can occur due to fluid shifts and inadequate free water replacement. Although it requires monitoring and adjustment of fluid therapy, it does not pose the same immediate risk as hyperkalemia.
D. Urine specific gravity 1.005: This value suggests dilute urine, which may indicate adequate hydration or early renal impairment. While it warrants monitoring in the context of burn resuscitation, it does not require urgent intervention compared with a dangerously high potassium level.
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