Which of the following is an appropriate nursing intervention for a patient with a pulmonary artery catheter?

Assist with ambulation

Administer a diuretic medication

Administer a vasopressor medication

Monitor central venous pressure

Answer and Explanation

The Correct Answer is D

D. Monitoring central venous pressure (CVP) is an appropriate nursing intervention for a patient with a pulmonary artery catheter. While the pulmonary artery catheter primarily provides information about pulmonary artery pressures and cardiac output, it can also be used to measure central venous pressure. Monitoring CVP can help assess the patient's fluid status, right ventricular function, and response to fluid resuscitation. This intervention is directly relevant to the presence of the pulmonary artery catheter and helps guide patient management.

A. Assist with ambulation: It's not typically appropriate to assist a patient with ambulation while they have a pulmonary artery catheter in place. This catheter is inserted into the pulmonary artery and is used to monitor various hemodynamic parameters such as pulmonary artery pressure, cardiac output, and mixed venous oxygen saturation. Ambulation could disrupt the catheter placement or lead to complications such as bleeding or dislodgement.

B. Administering a diuretic medication may not be directly related to the presence of a pulmonary artery catheter. The use of diuretics is typically based on the patient's clinical condition and the healthcare provider's assessment of their fluid status and renal function. While information obtained from the pulmonary artery catheter, such as pulmonary artery pressure and cardiac output, may inform the decision-making process regarding diuretic therapy, the catheter itself does not dictate the administration of diuretics.

C. Administering a vasopressor medication may be appropriate for a patient with a pulmonary artery catheter if they are experiencing hypotension or shock. However, the decision to administer vasopressors should be based on the patient's hemodynamic parameters as assessed through the pulmonary artery catheter monitoring, along with clinical judgment and consideration of the underlying cause of the hypotension.

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Correct Answer is A

Explanation

A The first intervention should be to ensure adequate oxygenation, as hypoxia can exacerbate shock. Therefore, providing oxygen at 100% via a non-rebreather mask is the most critical initial step. This intervention helps to maximize the amount of oxygen delivered to the patient's lungs and subsequently to the rest of the body, supporting vital organ function while further assessments and interventions are prepared.

B Continuous ECG monitoring allows for the assessment of the patient's heart rhythm, rate, and any signs of dysrhythmias or cardiac ischemia. This intervention is important for detecting any life- threatening arrhythmias, such as ventricular tachycardia or fibrillation, which may require immediate intervention. While ECG monitoring is important, it may not be the highest priority intervention.

C Drawing blood for type and crossmatch is important for preparing for potential blood transfusions if significant blood loss is suspected. However, this intervention may take some time to process, and immediate stabilization of the patient's condition is paramount.

D Large-bore IV catheters allow for rapid infusion of fluids to restore intravascular volume and improve tissue perfusion. This intervention is critical for stabilizing the patient's hemodynamic status and takes precedence in the management of shock. However, oxygenation should take priority.

A. Check the tubing connections for leaks. B. Continue to monitor the client's respiratory status. C. Check the suction control outlet on the wall. D. Clamp the chest tube.

Correct Answer is B

Explanation

B. In a closed chest drainage system, slow and steady bubbling in the suction control chamber is typically an expected finding, as it indicates that the suction is active and functioning properly

A. Checking the tubing connections for leaks or the suction control outlet on the wall might be necessary if there were signs of a problem with the system's function.

C. Checking the suction control outlet on the wall is a reasonable action to ensure that the suction source is functioning appropriately and delivering the prescribed suction pressure to the chest drainage system. If there are any issues with the suction control outlet, they should be addressed to maintain proper suction.

D. Clamping the chest tube is not indicated based solely on the presence of slow, steady bubbling in the suction control chamber. Clamping the chest tube could obstruct drainage and lead to complications such as tension pneumothorax or retained hemothorax.

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Which of the following is an appropriate nursing intervention for a patient with a pulmonary artery catheter?

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