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.

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. "The catheter will be in position until the heart has a chance to heal." B. The catheter will allow the provider to better manage fluid therapy." C. "The catheter tip comes to rest inside my brother's left ventricle." D. "The catheter will provide multiple IV sites to give intravenous fluid."

Correct Answer is B

Explanation

A. While a CVP catheter might be in place for an extended period, its purpose is not directly related to heart healing.

B. The CVP catheter is used to monitor central venous pressure, which helps guide fluid management and assess right heart function.

C. The CVP catheter does not extend into the left ventricle; it is typically positioned in the superior vena cava or right atrium.

D. The CVP catheter may have multiple lumens for administering fluids, but its primary purpose is hemodynamic monitoring, not just providing IV access.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is educating a patient's family member about a central venous pressure catheter (CVP). Which statement by the family member best indicates understanding of the purpose of the CVP?

Correct Answer is B

Explanation

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