The nurse is evaluating a client's central venous pressure (CVP) also called right atrial pressure (RAP) readings that are trending upwards. Which nursing problem is supported by the pathophysiologic mechanism most likely causing the increases?

Decreased cardiac output.

Ineffective airway clearance.

Ineffective peripheral tissue perfusion.

Deficient fluid volume.

Answer and Explanation

The Correct Answer is A

A. Decreased cardiac output. Central venous pressure (CVP), also called right atrial pressure (RAP), reflects right ventricular preload and overall fluid status. An increasing CVP indicates fluid overload or impaired right ventricular function, both of which can lead to decreased cardiac output. Conditions such as right heart failure, pulmonary hypertension, or excessive fluid resuscitation can cause elevated CVP, reducing the heart’s ability to pump effectively and leading to poor systemic circulation.
B. Ineffective airway clearance. Airway clearance is not directly related to CVP measurements. While severe pulmonary conditions like ARDS or COPD can contribute to cardiac strain and right heart failure, the primary mechanism for rising CVP is cardiac dysfunction or fluid overload, not airway obstruction.
C. Ineffective peripheral tissue perfusion. Although decreased cardiac output can impair tissue perfusion, this choice is too broad. Increased CVP specifically reflects right-sided heart function and preload, making decreased cardiac output the more precise diagnosis related to the pathophysiologic mechanism.
D. Deficient fluid volume. A low CVP is associated with hypovolemia and fluid deficits, while an increasing CVP suggests fluid overload, heart failure, or venous congestion. Deficient fluid volume would cause a downward trend in CVP, not an increase.

Nursing Test Bank

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Correct Answer is B

Explanation

A. Teach communication board use. While nonverbal communication tools are helpful for intubated clients, they do not directly prevent complications associated with mechanical ventilation and ARDS. The priority in this critically ill client is to prevent ventilator-associated pneumonia (VAP) and sepsis-related complications.
B. Use antiseptic solution with oral care. Clients on mechanical ventilation are at high risk for ventilator-associated pneumonia (VAP), which worsens outcomes in ARDS. Using an antiseptic solution (such as chlorhexidine) for oral care reduces bacterial colonization in the oropharynx, decreasing the risk of VAP. This intervention is a key component of ventilator bundle protocols to improve survival rates in critically ill patients.
C. Recommend hours for visitation. While family support is important, setting visitation hours does not directly impact the client's recovery from ARDS and sepsis. Infection prevention and lung protection strategies take higher priority in the acute phase.
D. Promote uninterrupted periods of sleep. Rest is important for critically ill clients, but preventing life-threatening complications such as VAP, sepsis progression, and oxygenation failure takes precedence. Proper oral care with antiseptics directly reduces infection risk and improves patient outcomes.

A. Expel the excess air and heparin from the syringe. B. Place sample in arterial blood gas syringe. C. Obtain a minimum of 1 mL of blood. D. Aspirate the blood sample slowly.

Correct Answer is C

Explanation

A. Expel the excess air and heparin from the syringe. While removing excess air prevents gas exchange alterations, this is not the priority when obtaining an SVO₂ sample. Excess heparin could dilute the sample, but proper blood volume collection is the first concern.
B. Place sample in arterial blood gas syringe. SVO₂ measures venous oxygen saturation, which is different from arterial blood gases (ABGs). Using an ABG syringe is incorrect because it is heparinized for arterial sampling, and arterial blood does not reflect mixed venous oxygenation.
C. Obtain a minimum of 1 mL of blood. SVO₂ is measured from the distal lumen of a pulmonary artery (PA) catheter to assess oxygen delivery and consumption. At least 1 mL of blood is required for an accurate reading, ensuring sufficient sample volume for laboratory analysis.
D. Aspirate the blood sample slowly. While slow aspiration can help prevent hemolysis, it is not the primary concern when collecting an SVO₂ sample. The priority is obtaining a sufficient volume (≥1 mL) for an accurate measurement.

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The nurse is evaluating a client's central venous pressure (CVP) also called right atrial pressure (RAP) readings that are trending upwards. Which nursing problem is supported by the pathophysiologic mechanism most likely causing the increases?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the intensive care unit (ICU) with sepsis and acute respiratory distress syndrome (ARDS). The client is orally intubated and mechanically ventilated. Which intervention is most important for the nurse to include in the client's plan of care (POC)?

Correct Answer is B

Explanation

The nurse is collecting a blood sample for a mixed venous oxygen saturation (SVO2) level from the distal lumen of a pulmonary artery (PA) catheter of a client in cardiogenic shock. Which action should the nurse implement?

Correct Answer is C

Explanation

A client is brought to the emergency department (ED) following a motor vehicle collision with blunt trauma to the chest. Which finding should the nurse report immediately to the healthcare provider (HCP)?

Exhibits Click to mark whether the actions are indicated, contraindicated, or nonessential for this client. Each row must have one option selected.

An adult with head and facial injuries from a motor vehicle collision is fully immobilized and has a Glasgow coma score of 6. The client is intubated, sedated, and is being prepared for transfer to a regional trauma center. Which intervention(s) should the nurse implement? Select all that apply.

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