A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP should the nurse make?
Fluid overload
Intracardiac shunt
Hypovolemia
Left ventricular failure
The Correct Answer is C
Choice A Reason: This is incorrect because fluid overload is a condition of excess fluid volume in the body. A client who has fluid overload is more likely to have a high CVP, which indicates increased pressure in the right atrium and vena cava.
Choice B Reason: This is incorrect because an intracardiac shunt is a condition of abnormal blood flow between the chambers of the heart. A client who has an intracardiac shunt may have a normal or high CVP, depending on the direction and magnitude of the shunt.
Choice C Reason: This is correct because hypovolemia is a condition of low fluid volume in the body. A client who has hypovolemia is more likely to have a low CVP, which indicates decreased pressure in the right atrium and vena cava.
Choice D Reason: This is incorrect because left ventricular failure is a condition of impaired pumping function of the left ventricle. A client who has left ventricular failure may have a normal or high CVP, depending on the degree of backward failure and pulmonary congestion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: Continuous bubbling in the water-seal chamber indicates an air leak in the chest tube system, which can compromise the drainage of air and fluid from the pleural space and impair lung expansion.
Choice B Reason: Occasional bubbling in the water-seal chamber is normal and expected, as it indicates that air is being removed from the pleural space.
Choice C Reason: Fluctuations in the fluid level in the water-seal chamber are normal and expected, as they reflect changes in intrathoracic pressure during inspiration and expiration.
Choice D Reason: Constant bubbling in the suction-control chamber is normal and expected, as it indicates that suction is being applied to the chest tube system.
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because monitoring the client's electrolyte levels is not the highest priority, as it does not address the immediate risk of airway obstruction or aspiration.
Choice B Reason: This is correct because suctioning saliva from the client's mouth is the highest priority, as it prevents airway obstruction and aspiration, which can lead to respiratory distress and infection.
Choice C Reason: This is incorrect because recording the client's intake and output is not the highest priority, as it does not address the immediate risk of airway obstruction or aspiration.
Choice D Reason: This is incorrect because performing passive range of motion on each extremity is not the highest priority, as it does not address the immediate risk of airway obstruction or aspiration.
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