The ICU charge nurse will evaluate that teaching about hemodynamic monitoring for a new staff nurse has been effective when the new nurse does which of the following?
Position the limb with the catheter insertion site at the level of the transducer.
Positions the transducer level with the phlebostatic axis.
Ensures that the patient is lying with the head of the bed flat for all readings.
Balances and calibrates the hemodynamic monitoring equipment every hour.
The Correct Answer is B
Positioning the transducer level with the phlebostatic axis is a crucial step in accurate hemodynamic monitoring. The phlebostatic axis is an imaginary reference point located at the fourth intercostal space, mid-anterior/posterior chest. Placing the transducer at this level ensures that the pressure measurements obtained are reflective of the patient's true hemodynamic status.
A. Positioning the limb with the catheter insertion site at the level of the transducer in (option A) is incorrect because: While it is important to position the limb appropriately to avoid kinks or occlusions in the catheter tubing, this is not directly related to the accurate measurement of hemodynamic parameters.
C. Ensuring that the patient is lying with the head of the bed flat for all readings in (option C) is incorrect because The position of the patient's head does not directly impact the accuracy of hemodynamic monitoring unless it specifically relates to changes in preload or intracranial pressure monitoring.
D. Balancing and calibrating the hemodynamic monitoring equipment every hour in (option D) is incorrect because: While it is important to ensure that the monitoring equipment is calibrated and functioning properly, doing so every hour may not be necessary. Calibration frequency may vary based on institutional policies and patient stability.
Therefore, the correct action that demonstrates effective teaching about hemodynamic monitoring is positioning the transducer level with the phlebostatic axis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
In the early stage of septic shock, the body initiates compensatory mechanisms to combat the infection and restore adequate tissue perfusion. Tachypnoea (rapid breathing) and tachycardia (elevated heart rate) are common early signs of septic shock.
Tachypnoea occurs as a response to increased metabolic demand and to compensate for impaired oxygenation and tissue perfusion. Tachycardia is the body's attempt to maintain cardiac output and compensate for decreased blood pressure.
B. Pallor and cool skin in (option B) is incorrect because Pallor and cool skin can occur in later stages of septic shock when perfusion to the peripheral tissues is compromised. However, they are not specific to the early stage.
C. Blood pressure 84/50 mm Hg in (option C) is incorrect because A blood pressure reading of 84/50 mm Hg indicates hypotension, which is typically seen in later stages of septic shock. In the early stage, blood pressure may still be within normal or slightly decreased range.
D. Respiratory acidosis in (optionD) is incorrect because: Respiratory acidosis refers to an imbalance in acid-base status and is not specific to the early stage of septic shock. Acid-base disturbances may occur at any stage of shock but are not indicative of the early stage.
Correct Answer is B
Explanation
Disseminated Intravascular Coagulation (DIC) is a condition characterized by widespread activation of the coagulation system, leading to both excessive clot formation and consumption of clotting factors and platelets. This process can result in both bleeding and thrombosis.
The manifestations mentioned in option B are commonly seen in DIC:
Decreased platelet counts: DIC leads to platelet consumption and destruction, resulting in low platelet counts (thrombocytopenia).
Increased D-dimer: D-dimer is a fibrin degradation product, and its levels are increased DIC due to the breakdown of fibrin clots.
Increased prothrombin time (PT): DIC can lead to the depletion of clotting factors, resulting in prolonged prothrombin time, indicating impaired coagulation.
The other options mentioned do not represent the typical clinical manifestations of DIC:
A. Decreased hematocrit, increased platelet counts, and increased D-dimer in (option A) are incorrect because While platelet counts and D-dimer are increased in DIC, decreased hematocrit is not a characteristic finding.
C. Decreased Antithrombin III, increased platelet counts, and increased fibrinogen in (option C) is incorrect because: Decreased Antithrombin III can be seen in DIC, but increased platelet counts and fibrinogen levels are not specific to DIC.
D. Decreased D-dimer, increased platelet counts, and increased hemoglobin in (option D) is incorrect because Decreased D-dimer and increased hemoglobin are not typical findings in DIC, while increased platelet counts can be seen in some cases.
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