Chapter 08 Hemodynamic Monitoring PDF

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Sole: Introduction to Critical Care Nursing, 5th Edition Chapter 08: Hemodynamic Monitoring Test Bank MULTIPLE CHOICE 1. The nurse is caring for a 100 kg patient being monitored with a pulmonary artery catheter. The nurse assesses a blood pressure of 90/60 mm Hg, heart rate 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation. Which hemodynamic value requires immediate action by the nurse? a. b. c. d.

Cardiac index (CI) of 1.2 L/min/m3 Cardiac output (CO) of 4 L/min Pulmonary vascular resistance (PVR) of 80 dynes/sec/cm-5 Systemic vascular resistance (SVR) of 1800 dynes/sec/cm-5

ANS: A A cardiac index of 1.2 L/min/m3 combined with the identified clinical assessment findings indicate a low cardiac output with fluid overload (bilateral crackles) requiring intervention. Incorrect: B: A cardiac output of 4 L/min is normal. C: Pulmonary vascular resistance of 80 dynes/sec/cm-5 is normal. D: Systemic vascular resistance of 1800 dynes/sec/cm-5 is normal. DIF: Cognitive Level: Application REF: Page 163 OBJ: Articulate appropriate nursing actions for patients with alterations in hemodynamic values. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiologic Integrity 2. While caring for a patient with a small bowel obstruction, the nurse assesses a pulmonary artery occlusive pressure (PAOP/PCWP) of 1 mm Hg and hourly urine output of 5 mL. The nurse anticipates which therapeutic intervention? a. Diuretics b. Intravenous fluids

c. Negative inotropic agents d. Vasopressors

ANS: B Low pulmonary artery occlusive pressures usually indicate volume depletion, so intravenous fluids would be indicated.

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Incorrect: A: Administration of diuretics would worsen the patient’s volume status. C: Negative inotropes would not improve the patient’s volume status. D: Vasopressors will increase blood pressure but are contraindicated in a low volume state. DIF: Cognitive Level: Analysis REF: Page 148 | Table 8-1 OBJ: Articulate appropriate nursing actions for patients with alterations in hemodynamic values. TOP: Nursing Process Step: Planning. MSC: NCLEX: Physiological Adaptation 3. The nursing is caring for a patient following insertion of an arterial line. To reduce the risk of complications, what is the priority nursing intervention? a. b. c. d.

Apply a pressure dressing to the insertion site Ensure all tubing connections are tightened Obtain a portable x-ray study to confirm placement Restrain the extremity for 24 hours

ANS: B Loose connections in hemodynamic monitoring tubing can lead to hemorrhage, a major complication of arterial pressure monitoring. Incorrect: A: Application of a pressure dressing is required only upon arterial line removal. C: Blood return is adequate confirmation of arterial line placement; x-ray studies are not performed. D: Neutral positioning of the extremity and use of an arm board, without restraint, is the standard of care. DIF: Cognitive Level: Application REF: Page 156 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

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4. While caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary artery occlusive pressure (PAOP/PCWP) 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? a. b. c. d.

Increase supplemental oxygen and notify respiratory therapy Notify the physician immediately of the assessment findings Obtain a stat chest x-ray film to verify proper catheter placement Zero reference and level the catheter at the phlebostatic axis

ANS: D A hemodynamic value not supported by clinical assessment should be treated as questionable. To ensure the accuracy of hemodynamic readings, the catheter transducer system must be leveled at the phlebostatic axis and zero referenced. In this example, the catheter transducer system may be lower than the phlebostatic axis, resulting in erroneously higher pressures. Incorrect: A: Clinical manifestations do not support increasing supplemental oxygen. B: Clinical manifestations do not warrant physician intervention; aberrant values should be investigated further. C: An aberrant value warrants further investigation, which includes zero referencing and checking the level as an initial measure. A chest x-ray study is not warranted at this time. DIF: Cognitive Level: Synthesis REF: Page 154 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices. TOP: Nursing Process Step: Intervention. MSC: NCLEX: Physiological Integrity 5. A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135 beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vascular resistance of 3000 dynes/sec/ cm-5, and a hematocrit of 20%. The nurse anticipates administration of which the following therapies or medications? a. b. c. d.

Blood and intravenous crystalloids Colloids and furosemide (Lasix) Dobutamine (Dobutrex) infusion Dopamine hydrochloride (Dopamine) infusion

Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

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ANS: A Both hemodynamic parameters and the reported hematocrit value indicate hypovolemia and blood loss requiring volume resuscitation with crystalloid fluids and blood products. Incorrect: B: Colloid administration will not correct the underlying anemia, and furosemide administration will worsen fluid volume status. C: Inotropic agents will not correct the underlying fluid volume deficit and anemia. D: Vasoconstrictors are contraindicated in a volume-depleted state. DIF: Cognitive Level: Application REF: Page 163 | Box 8-8 OBJ: Articulate appropriate nursing actions for patients with alterations in hemodynamic values. TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 6. After pulmonary artery catheter insertion, the nurse assesses a pulmonary artery pressure of 45/25 mm Hg, a pulmonary artery occlusion pressure (PAOP) of 20 mm Hg, a cardiac output of 2.6 L/ minute and a cardiac index of 1.9 L/min/m2. What is the best interpretation of these findings by the nurse? a. b. c. d.

Elevated afterload and low cardiac output Elevated preload and afterload Elevated preload and low cardiac output Values are normal for the patient

ANS: C The pulmonary pressures are higher than normal, indicating elevated preload, and the cardiac index and output values are low. Incorrect: A: This patient has a low cardiac output/index; however, the afterload values are not reported (e.g., SVR). B: This patient has an elevated preload; however, the afterload values are not reported (e.g., SVR). D: Hemodynamic values are outside of normal limits. The pulmonary pressures are higher than normal, indicating elevated preload, and the cardiac index and output values are low. DIF: Cognitive Level: Knowledge REF: Page 163 | Box 8-8 OBJ: Identify normal hemodynamic values. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

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7. The nurse is caring for a patient with a left subclavian central venous catheter (CVC) and a left radial arterial line. Which assessment finding by the nurse requires immediate action? a. b. c. d.

A dampened arterial line waveform Numbness and tingling in the left hand Slight bloody drainage at subclavian insertion site Slight redness at subclavian insertion site

ANS: B Numbness and tingling in the left hand, which is the location of an arterial catheter, indicates possible neurovascular compromise and requires immediate action. Incorrect: A: A dampened waveform can indicate problems with arterial line patency but is not an emergent situation. C: Slight bloody drainage at the subclavian insertion site is not an unusual finding. D: Slight redness at the insertion site, while of concern, does not require immediate action. DIF: Cognitive Level: Application REF: Page 150 | Box 8-2 TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 8. The physician writes an order to discontinue a patient’s left radial arterial line. When discontinuing the patient’s invasive line, what is the priority nursing action? a. b. c. d.

Apply an air occlusive dressing to insertion site Apply pressure to the insertion site for 5 minutes Elevate the affected limb on pillows for 24 hours Keep the patient’s wrist in a neutral position

ANS: B Upon removal of an invasive arterial line, adequate pressure must be applied for at least 5 minutes to ensure adequate hemostasis. Incorrect: A: Air occlusive dressings are not required following removal of an arterial line. C: Elevation of the limb following removal of an arterial line is not a necessary intervention. D: Neutral wrist position is optimum while the catheter is in place and not necessary after catheter discontinuation.

Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

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DIF: Cognitive Level: Comprehension REF: Page 157 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices. TOP: Nursing Process Step: Intervention. MSC: NCLEX: Physiological Integrity 9. Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to verify proper catheter placement. The radiologist reports to the nurse: “The tip of the catheter is located in the superior vena cava.” What is the best interpretation of these results by the nurse? a. b. c. d.

The catheter is not positioned correctly and should be removed. The catheter position increases the risk of ventricular dysrhythmias. The distal tip of the catheter is in the appropriate position. The physician should be called to advance the catheter into the pulmonary artery.

ANS: C The tip of the central venous catheter should rest just above the right atrium in the superior vena cava. Incorrect: A: The central venous catheter is correctly positioned in the superior vena cava. B: X-ray results indicate proper position of the catheter. Dysrhythmias occur if the catheter migrates to the right ventricle. D: Central venous catheters are placed into great vessels of the venous system and not advanced into the pulmonary artery. DIF: Cognitive Level: Comprehension REF: Page 158 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices. TOP: Nursing Process Step: Evaluation.MSC: NCLEX: Physiological Integrity 10. While inflating the balloon of a pulmonary artery catheter (PAC) with 1.0 mL of air to obtain a pulmonary artery occlusion pressure (PAOP/PCWP), the nurse encounters resistance. What is the best nursing action? a. b. c. d.

Add an additional 0.5 mL of air to the balloon and repeat the procedure. Advance the catheter with the balloon deflated and repeat the procedure. Deflate the balloon and obtain a chest x-ray study to determine line placement. Lock the balloon in the inflated position and flush the distal port of the PAC with normal saline.

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ANS: C Balloon inflation should never be forced because the PAC may have migrated further into the pulmonary artery, creating resistance to balloon inflation. Verification of proper line placement is warranted to avoid pulmonary artery rupture. The PAC waveform should also be observed to assist in identifying location of the tip of the PAC. Incorrect: A: In this scenario, adding additional air to the balloon will further risk pulmonary artery rupture. B: Advancing a pulmonary artery catheter is not within the nurse’s scope of practice. And in this scenario, advancing the PAC may further increase the risk of pulmonary artery rupture. D: Flushing the distal port with saline may be indicated to ensure patency; however, the balloon of the PAC should never be locked in the inflated position as rupture of the pulmonary artery may occur. DIF: Cognitive Level: Application REF: Page 163 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 11. The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate action? a. b. c. d.

Diminished breath sounds over left lung field Localized pain at catheter insertion site Measured central venous pressure of 5 mm Hg Slight bloody drainage around insertion site

ANS: A Pneumothorax, which can develop slowly, is a major complication following insertion of central lines when the subclavian route is used. Incorrect: B: Localized pain at catheter insertion site is not the immediate priority in this scenario. C: A measured central venous pressure of 5 mm Hg is normal. D: Slight bloody drainage at the insertion site soon after the procedure does not require immediate action.

Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.

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DIF: Cognitive Level: Application REF: Page 162 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices. TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 12. The nurse is caring for a mechanically ventilated patient with a pulmonary artery catheter who is receiving continuous enteral tube feedings. When obtaining continuous hemodynamic monitoring measurements, what is the best nursing action? a. Do not document hemodynamic values until the patient can be placed in the supine position. b. Level and zero reference the air-fluid interface of the transducer with the patient in the supine position and record hemodynamic values. c. Level and zero reference the air-fluid interface of the transducer with the patient’s head of bed elevated to 30 degrees and record hemodynamic values. d. Level and zero reference the air-fluid interface of the transducer with the patient supine in the side-lying position and record hemodynamic values. ANS: C Elevation of the head of bed is an important intervention to prevent aspiration and ventilatorassociated pneumonia. Patients who require hemodynamic monitoring while receiving tube feedings should have the air-fluid interface of the transducer leveled with the phlebostatic axis while the head of bed is elevated to at least 30 degrees. Readings will be accurate. Incorrect: A: Supine positioning of a mechanically ventilated patient increases the risk of aspiration and ventilator-associated pneumonia and is contraindicated in this patient. B: Hemodynamic values can be accurately measured and trended in with the head of the bed elevated as high as 60 degrees. D: Even though hemodynamic values can be obtained in lateral positions, it is technically difficult and not accurate unless the positioning of the transducer is exact. Regardless, head of bed elevation is indicated for this patient. DIF: Cognitive Level: Application REF: Page 153 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

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13. The nurse is educating a patient’s family member about a pulmonary artery catheter (PAC). Which statement by the family member best indicates understanding of the purpose of the PAC?] a. b. c. d.

“The catheter will provide multiple sites to give intravenous fluid.” “The catheter will allow the physician to better manage fluid therapy.” “The catheter tip comes to rest inside my brother’s pulmonary artery.” “The catheter will be in position until the heart has a chance to heal.”

ANS: B A pulmonary artery catheter provides hemodynamic measurements that guide interventions that include appropriate fluid therapy. Incorrect: A: Even though a pulmonary catheter provides multiple intravenous access sites, this is not the primary purpose of the catheter. C: Although the catheter is positioned in the pulmonary artery, positioning is not the purpose of the catheter. D: This is not a purpose of the catheter. DIF: Cognitive Level: Comprehension REF: Page 162 OBJ: Describe the indications, measurement, complications, and nursing implications associated with monitoring of invasive right atrial, left atrial, pulmonary artery, and intraarterial pressures and those equated with noninvasive monitoring of hemodynamic indices. TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity 14. The nurse is preparing to obtain a pulmonary artery occlusive pressure (PAOP/PCWP) for a patient who is mechanically ventilated. Ensuring that the air-fluid interface is at the level of the phlebostatic axis, what is the best nursing action? a. Place the patient in the supine position and record the PAOP immediately after exhalation d. Place the patient with the head of bed elevated 30 degrees and record the PAOP just before the increase in pressures during inhalation b. Place the patient in the supine position and document the average PAOP pressure obtained after three measurements c. Place the patient with the head of bed elevated 30 degrees and document the average PAOP pressure obtained ANS: B Pressures are highest when measured at end exhalation in the spontaneously breathing patient. In mechanically ventilated patients, pressures increase with inhalation and decrease with exhalation. Measurements are obtained just before the increase in pressure during inhalation.

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Incorrect: A: Supine positioning is contraindicated in the mechanically ventilated patient. The head of bed should be elevated to 30 degrees. In mechanically ventilated patients, measurements are obtained jus...