The nurse notices a sudden increase in central venous pressure (CVP) readings for a client who is being monitored for fluid status.
Which condition is the most likely cause of this change?
Increased cardiac output.
Dehydration.
Right-sided heart failure.
Hypovolemia.
The Correct Answer is C
Hemodynamic monitoring requires knowledge of pressure dynamics within the right atrium and vena cava. Central venous pressure reflects right heart preload and fluid volume status. Increased readings indicate either fluid volume excess or impaired pumping ability of the right ventricle.
Choice A rationale
. Increased cardiac output typically relates to efficient ventricular contraction and does not directly cause an elevated central venous pressure. High output states might actually reflect lower pressures if the volume is moving effectively. It is not the primary cause of pressure backup.
Choice B rationale
. Dehydration leads to a decrease in circulating blood volume, which results in a low central venous pressure reading. Normal CVP ranges from 2 to 8 mmHg. A reading below this range typically indicates a need for intravenous fluid resuscitation.
Choice C rationale
. When the right ventricle fails, it cannot effectively pump blood into the pulmonary circulation. This causes blood to back up into the right atrium and vena cava. This congestion results in a measurable rise in the central venous pressure reading.
Choice D rationale
. Hypovolemia represents a state of low intravascular volume, which reduces the pressure exerted on the walls of the great veins. This leads to a decreased CVP reading. It is the physiological opposite of the volume overload seen in heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Nursing prioritization relies on the ABC framework and identifying the most immediate threat to life. Knowledge of electrolyte imbalances and cardiac conduction must be applied here to recognize that severe hyperkalemia poses an imminent risk of lethal cardiac arrhythmias.
Choice A rationale
A low grade fever of 38.2 C on the first postoperative day is common due to the inflammatory response or atelectasis. While it requires monitoring and lung expansion exercises, it is not an immediate life threat.
Choice B rationale
Severe abdominal pain and nausea are classic symptoms of acute pancreatitis. While the patient is in significant distress and needs analgesia, this presentation is expected for the diagnosis and is second to cardiovascular instability.
Choice C rationale
Confusion and asterixis in cirrhosis indicate hepatic encephalopathy due to elevated ammonia. Normal ammonia is 15 to 45 mcg/dL. This requires treatment with lactulose but is less immediately fatal than a cardiac arrest.
Choice D rationale
A potassium level of 6.8 mEq/L is critically high, as the normal range is 3.5 to 5.0 mEq/L. Peaked T waves indicate myocardial irritability, which can progress rapidly to ventricular fibrillation or asystole, requiring emergent intervention..
Correct Answer is A
Explanation
Post-operative skin graft care focuses on maximizing graft take by reducing edema and preventing shearing. Knowledge of tissue perfusion and fluid dynamics is necessary to prioritize actions that minimize swelling, which can lift the graft from the bed.
Choice A rationale
Elevating the affected extremity reduces edema at the graft site by promoting venous return. Excessive swelling can separate the new graft from the underlying vascular bed, preventing necessary revascularization and leading to graft failure or necrosis.
Choice B rationale
Inspecting the graft site is important, but the nurse should generally not disturb the initial surgical dressing. Frequent inspection increases the risk of shearing or dislodging the delicate graft before it has successfully adhered to the site.
Choice C rationale
Ensuring the patient does not lie on the graft is a standard intervention to prevent pressure and shearing. However, in the presence of noted edema, elevation is the priority action to ensure the graft remains viable.
Choice D rationale
Administering analgesics addresses the pain level of 6/10, which is important for comfort. However, pain is expected, whereas reducing edema through elevation is functionally more critical to the physiological success and survival of the graft.
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