While caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary artery pressure to be significantly higher than previously recorded values. The nurse assesses respirations to be unlabored at 16 breaths/min, oxygen saturation of 98% on 3 L of oxygen via nasal cannula, and lungs clear to auscultation bilaterally. What is the priority nursing action?
Obtain a stat chest x-ray to verify proper catheter placement.
Zero reference and level the catheter at the phlebostatic-axis.
Increase supplemental oxygen and notify respiratory therapy.
Notify the provider immediately of the assessment findings.
The Correct Answer is B
A. Obtaining a stat chest x-ray is important if catheter misplacement is suspected, but in this situation, ensuring the accuracy of the pressure reading through proper leveling and zeroing is the priority.
B. Zero referencing and leveling the catheter at the phlebostatic axis is essential to ensure accurate readings of the pulmonary artery pressure, which is critical for patient assessment and management.
C. Increasing supplemental oxygen is unnecessary given the patient’s stable oxygen saturation and normal respiratory status.
D. While notifying the provider is important, ensuring the accuracy of the pressure reading by leveling and zeroing the catheter should be done first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A coronary artery bypass graft is used to treat coronary artery disease but is not typically indicated for end-stage heart failure.
B. Percutaneous coronary intervention is also used for coronary artery disease, not for improving quality of life in terminal heart failure.
C. This option dismisses potential interventions that could improve quality of life, such as an LVAD.
D. An LVAD is a mechanical pump that assists the left ventricle in pumping blood, often used as a bridge to heart transplant or as a long-term solution to improve quality of life in patients with terminal heart failure.
Correct Answer is C
Explanation
A. A depressed ST-segment is often associated with ischemia or non-ST elevation myocardial infarction (NSTEMI), not an ongoing MI.
B. A depressed ST-segment with normal cardiac enzymes suggests ischemia rather than an active MI.
C. ST-segment elevation on ECG combined with elevated cardiac biomarkers such as CK-MB or troponin levels is a hallmark of an acute ST-segment elevation myocardial infarction (STEMI), indicating an ongoing MI.
D. A Q wave on ECG indicates an old infarction and is not associated with an acute MI if enzymes and troponin levels are normal.
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