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 A
Explanation
This scenario requires applying knowledge of safety protocols, legal standards for restraint use, and nursing delegation. Understanding that using sheets as makeshift restraints is illegal and dangerous is critical for maintaining patient safety and adhering to healthcare regulations regarding physical interventions.
Choice A rationale
Using sheets as restraints is a violation of safety standards and patient rights. Restraints require a specific medical order and must be manufactured devices. Improper tying can cause skin breakdown, strangulation, or impaired circulation in confused patients.
Choice B rationale
While smoking is generally discouraged in healthcare facilities, escorting a stable patient outdoors does not constitute an immediate safety emergency compared to illegal restraint. It requires a policy review rather than an emergency clinical intervention by the supervisor.
Choice C rationale
Assisting with ambulation is a standard task for unlicensed personnel. In a rehabilitation unit, promoting mobility is a key goal. This action is appropriate unless the patient is specifically designated as bedrest or requires a therapist.
Choice D rationale
Providing a beverage is generally within the scope of unlicensed staff unless the patient is NPO or on a restricted diet. While carbonation may not be ideal, it does not pose an immediate physical threat.
Correct Answer is D
Explanation
Analyzing arterial blood gas results requires understanding the relationship between hydrogen ion concentration, carbon dioxide levels, and bicarbonate. Knowledge of respiratory physiology is essential to determine if the primary imbalance stems from gas exchange failure or metabolic dysfunction in the body.
Choice A rationale
Metabolic acidosis is defined by a low pH and a low bicarbonate level below 22 mEq/L. In this case, the bicarbonate is 26 mEq/L, which is within the normal range of 22 to 28 mEq/L, ruling it out.
Choice B rationale
Respiratory alkalosis occurs when the pH is above 7.45 and the PaCO2 is below 35 mm Hg. This client has a low pH of 7.22 and a high PaCO2 of 68 mm Hg, which indicates an acidotic state.
Choice C rationale
Metabolic alkalosis is characterized by a high pH above 7.45 and an elevated bicarbonate level. This client presents with a low pH and a normal bicarbonate level, which does not fit the criteria for a metabolic alkalotic imbalance.
Choice D rationale
The pH of 7.22 is below 7.35, indicating acidosis. The PaCO2 of 68 mm Hg is above the normal 35 to 45 mm Hg range, confirming a respiratory cause. A respiratory rate of 7/min causes CO2 retention.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.