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 B
Explanation
A. Epinephrine is an important drug in resuscitation but is administered after defibrillation in the algorithm.
B. Defibrillation is the priority intervention for ventricular fibrillation, as it is the only treatment that can convert the heart rhythm back to a viable one.
C. Airway management is crucial, but in the context of ventricular fibrillation, defibrillation takes precedence to restore a life-sustaining rhythm.
D. Amiodarone is used in the treatment of refractory ventricular fibrillation, but it is not the immediate priority over defibrillation.
Correct Answer is A
Explanation
A. Thrombolytic therapy is the priority in managing an ST-elevated myocardial infarction (STEMI) when percutaneous coronary intervention (PCI) is not available. It helps dissolve the blood clot causing the blockage in the coronary artery.
B. Maintaining oxygen saturation is important, but the priority is to restore coronary blood flow.
C. The focus should be on stabilizing the heart rhythm, not specifically maintaining a high heart rate.
D. Diuretics are important in managing heart failure but are not the priority in acute STEMI management.
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