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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A Reason: This is correct because using log rolling to reposition the client helps maintain the alignment of the head and neck, which prevents further increases in ICP.

Choice B Reason: This is incorrect because placing a warming blanket on the client can cause vasodilation and increase cerebral blood ﬂow, which can raise ICP.

Choice C Reason: This is incorrect because instructing the client to cough and deep breathe can increase intrathoracic pressure and impede venous return, which can elevate ICP.

Choice D Reason: This is incorrect because placing the client in a supine position can decrease cerebral perfusion pressure and increase ICP. The client should be placed in a semi-Fowler's position with the head elevated at 30 degrees.

A. Clamp the client's chest tube. B. Increase the client's wall suction. C. Reposition the client. D. Strip the client's chest tube.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because clamping the client's chest tube can cause a tension pneumothorax, which is a life-threatening condition that requires immediate intervention.

Choice B Reason: This is incorrect because increasing the client's wall suction can cause excessive negative pressure in the pleural space, which can damage the lung tissue and impair ventilation.

Choice C Reason: This is correct because repositioning the client can help relieve chest burning, which may be caused by irritation of the intercostal nerves by the chest tube or by air trapping in the pleural space.

Choice D Reason: This is incorrect because stripping the client's chest tube can create high negative pressure in the pleural space, which can damage the lung tissue and impair ventilation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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