While caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary artery pressure to be significantly higher than previously recorded values. The nurse assesses respirations to be unlabored at 16 breaths/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally. What is the priority nursing action?
Obtain a stat chest x-ray to verify proper catheter placement.
Zero reference and level the catheter at the phlebostatic-axis.
Increase supplemental oxygen and notify respiratory therapy.
Notify the provider immediately of the assessment findings.
The Correct Answer is B
A. Obtaining a stat chest x-ray is important if catheter misplacement is suspected, but in this situation, ensuring the accuracy of the pressure reading through proper leveling and zeroing is the priority.
B. Zero referencing and leveling the catheter at the phlebostatic axis is essential to ensure accurate readings of the pulmonary artery pressure, which is critical for patient assessment and management.
C. Increasing supplemental oxygen is unnecessary given the patient’s stable oxygen saturation and normal respiratory status.
D. While notifying the provider is important, ensuring the accuracy of the pressure reading by leveling and zeroing the catheter should be done first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. CK-MB is a cardiac enzyme that rises in response to myocardial injury, but it is less specific and takes longer to rise than troponin.
B. BNP is associated with heart failure, not myocardial infarction.
C. Myoglobin is an early marker but is non-specific, as it rises with any muscle damage.
D. Troponin is the most specific and sensitive biomarker for myocardial infarction. It rises within 3-4 hours after myocardial injury and remains elevated for days, making it the most useful test for confirming an MI.
Correct Answer is C
Explanation
A. Secondary hypertension is high blood pressure due to an identifiable cause, such as renal disease, but it does not describe an acute situation with target organ damage.
B. Hypertensive urgency is a situation where the blood pressure is severely elevated but without evidence of target organ damage.
C. Hypertensive emergency is characterized by severely elevated blood pressure with evidence of acute target organ damage, such as encephalopathy, myocardial infarction, or renal failure, requiring immediate medical intervention.
D. Primary hypertension, also known as essential hypertension, is high blood pressure without a known secondary cause and does not describe an acute emergency.
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