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 {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
Administer furosemide IV: Furosemide is a diuretic used to manage fluid overload, which is not the primary concern in this scenario. The client presents with chest pain suggestive of a cardiac event, so other interventions should take priority.
Prepare the client for intubation: Intubation is not indicated at this stage as the patient is conscious, has a respiratory rate of 18/min, and there is no immediate indication of airway compromise. Oxygen therapy is more appropriate.
Obtain the client’s full family history: While obtaining a full family history is important for a comprehensive assessment, it is not a high priority in the acute management of this client who presents with symptoms suggestive of a myocardial infarction (MI).
Administer O2 to maintain oxygen saturation greater than 90%: The client’s oxygen saturation is 88%, which is below the desired level. Administering oxygen to maintain saturation greater than 90% is a high-priority intervention to improve oxygenation.
Apply continuous ECG monitoring: Continuous ECG monitoring is essential in this scenario to monitor for arrhythmias and assess for ongoing ischemia, given the client’s chest pain, irregular pulse, and the high likelihood of an acute coronary syndrome.
Obtain vascular access: Establishing vascular access is a high priority to ensure the ability to administer medications, fluids, and for potential blood draws, especially in an emergency setting where rapid intervention may be necessary.
Correct Answer is C
Explanation
A. Passive range of motion may be performed, but it is not the priority in this situation.
B. The head of the bed should be elevated 30 degrees or less, not necessarily flat, to prevent complications.
C. Hourly urinary output measurement is essential because the intra-aortic balloon pump (IABP) can impair renal perfusion, and monitoring urine output helps assess renal function.
D. Anticoagulants are often necessary to prevent clot formation associated with the IABP, so avoiding them is not advised unless contraindicated.
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