The nurse is caring for a patient with a left radial arterial line and a pulmonary artery catheter inserted into the right subclavian vein. Which action by the nurse best ensures the safety of the patient being monitored with invasive hemodynamic monitoring lines?
Document all waveform values.
Limit the pressure tubing length.
Zero reference the system daily.
Ensure alarm limits are turned on
The Correct Answer is D
A. Documentation of waveform values is important but does not directly enhance patient safety during monitoring.
B. Limiting the pressure tubing length can help maintain accuracy, but it is not the primary safety measure.
C. Zero referencing is crucial for accurate readings, but it must be done in conjunction with ensuring alarms are active.
D. Ensuring that alarm limits are turned on and appropriately set is the best safety measure to immediately alert the nurse to any critical changes in the patient's status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. CK-MB is a cardiac enzyme that rises in response to myocardial injury, but it is less specific and takes longer to rise than troponin.
B. BNP is associated with heart failure, not myocardial infarction.
C. Myoglobin is an early marker but is non-specific, as it rises with any muscle damage.
D. Troponin is the most specific and sensitive biomarker for myocardial infarction. It rises within 3-4 hours after myocardial injury and remains elevated for days, making it the most useful test for confirming an MI.
Correct Answer is A
Explanation
A. Sudden weight gain can indicate fluid retention, a common early sign of heart failure exacerbation. Prompt reporting allows for early intervention.
B. Nitroglycerin is used to treat chest pain, not specifically to prevent heart failure exacerbations.
C. Assessment of the apical pulse is important, but monitoring weight is more directly related to managing heart failure.
D. Compliance with diuretic therapy is important, but recognizing early signs of fluid retention, such as rapid weight gain, is crucial for preventing exacerbations.
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