TEST BANK QUESTIONS: CRITICAL EXAM 3 AND FINAL EXAM
QUESTIONS AND ANSWERS UPDATE 2024/2025 ALL ANSWERS 100%
CORRECT VERIFIED BEST EXAM SOLUTION RATED A+ FOR SUCCESS
Begin a dobutamine (Dobutrex) infusion.
d.
Obtain stat cardiac enzymes and troponin.
ANS: B
Numbness and tingling in the left hand, which is the location of an arterial catheter, indicates
possible neurovascular compromise and requires immediate action. A dampened waveform
can indicate problems with arterial line patency but is not an emergent situation. Slight
bloody drainage at the subclavian insertion site is not an unusual finding. Slight redness at
the insertion site, while of concern, does not require immediate action. - CORRECT
ANSWERS The nurse is caring for a patient with a left subclavian central venous catheter
(CVC) and a left radial arterial line. Which assessment finding by the nurse requires
immediate action?
a.
A dampened arterial line waveform
b.
Numbness and tingling in the left hand
c.
Slight bloody drainage at subclavian insertion site
d.
Slight redness at subclavian insertion site
ANS: B
Upon removal of an invasive arterial line, adequate pressure must be applied for at least 5
minutes to ensure adequate hemostasis. Application of an air occlusion dressing is not
standard of care following removal of an arterial line. Elevation of the affected limb following
removal of an arterial line is not a necessary intervention. Neutral wrist position is optimum
while the catheter is in place and not necessary after catheter discontinuation. - CORRECT
ANSWERS The physician writes an order to discontinue a patient's left radial arterial line.
When discontinuing the patient's invasive line, what is the priority nursing action?
a.
Apply an air occlusion dressing to insertion site.
b.
Apply pressure to the insertion site for 5 minutes.
dr.j
,TEST BANK QUESTIONS: CRITICAL EXAM 3 AND FINAL EXAM
QUESTIONS AND ANSWERS UPDATE 2024/2025 ALL ANSWERS 100%
CORRECT VERIFIED BEST EXAM SOLUTION RATED A+ FOR SUCCESS
c.
Elevate the affected limb on pillows for 24 hours.
d.
Keep the patient's wrist in a neutral position.
ANS: C
X-ray results indicate proper position of the catheter. The tip of the central venous catheter
should rest just above the right atrium in the superior vena cava. The central venous
catheter is positioned correctly in the superior vena cava. Dysrhythmias occur if the catheter
migrates to the right ventricle. Central venous catheters are placed into great vessels of the
venous system and not advanced into the pulmonary artery. - CORRECT ANSWERS
Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to
verify proper catheter placement. The radiologist reports to the nurse: "The tip of the
catheter is located in the superior vena cava." What is the best interpretation of these
results by the nurse?
a.
The catheter is not positioned correctly and should be removed.
b.
The catheter position increases the risk of ventricular dysrhythmias.
c.
The distal tip of the catheter is in the appropriate position.
d.
The physician should be called to advance the catheter into the pulmonary artery.
ANS: C
Balloon inflation should never be forced because the PAC may have migrated further into the
pulmonary artery, creating resistance to balloon inflation. Verification of proper line
placement is warranted to avoid pulmonary artery rupture. In addition, the PAC waveform
should be observed to assist in identifying location of the tip of the PAC. In this scenario,
adding additional air to the balloon will further risk pulmonary artery rupture.
Advancing a pulmonary artery catheter is not within the nurse's scope of practice.
Flushing the distal port with saline may be indicated to ensure patency; however, the
balloon of the PAC should never be locked in the inflated position as rupture of the
pulmonary artery may occur. - CORRECT ANSWERS 10. While inflating the balloon of a
dr.j
,TEST BANK QUESTIONS: CRITICAL EXAM 3 AND FINAL EXAM
QUESTIONS AND ANSWERS UPDATE 2024/2025 ALL ANSWERS 100%
CORRECT VERIFIED BEST EXAM SOLUTION RATED A+ FOR SUCCESS
pulmonary artery catheter (PAC) with 1.0 mL of air to obtain a pulmonary artery occlusion
pressure (PAOP), the nurse encounters resistance. What is the best nursing action?
a.
Add an additional 0.5 mL of air to the balloon and repeat the procedure.
b.
Advance the catheter with the balloon deflated and repeat the procedure.
c.
Deflate the balloon and obtain a chest x-ray study to determine line placement.
d.
Lock the balloon in the inflated position and flush the distal port of the PAC with normal
saline.
ANS: A
Diminished breaths sounds over the lung field on the same side of the line insertion site may
be indicative of a pneumothorax. A pneumothorax, which can develop slowly, is a major
complication following insertion of central lines when the subclavian route is used. Localized
pain at catheter insertion site is not the immediate priority in this scenario. A measured
central venous pressure of 5 mm Hg is normal. Slight bloody drainage at the insertion site
soon after the procedure does not require immediate action. - CORRECT ANSWERS The
nurse is caring for a patient following insertion of a left subclavian central venous catheter
(CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate
action?
a.
Diminished breath sounds over left lung field
b.
Localized pain at catheter insertion site
c.
Measured central venous pressure of 5 mm Hg
d.
Slight bloody drainage around insertion site
ANS: C
Elevation of the head of bed is an important intervention to prevent aspiration and
ventilator-associated pneumonia. Patients who require hemodynamic monitoring while
dr.j
, TEST BANK QUESTIONS: CRITICAL EXAM 3 AND FINAL EXAM
QUESTIONS AND ANSWERS UPDATE 2024/2025 ALL ANSWERS 100%
CORRECT VERIFIED BEST EXAM SOLUTION RATED A+ FOR SUCCESS
receiving tube feedings should have the air-fluid interface of the transducer leveled with the
phlebostatic axis while the head of bed is elevated to at least 30 degrees. Readings will be
accurate. Supine positioning of a mechanically ventilated patient increases the risk of
aspiration and ventilator-associated pneumonia and is contraindicated in this patient.
Hemodynamic values can be accurately measured and trended in with the head of the bed
elevated as high as 60 degrees. Even though hemodynamic values can be obtained in lateral
positions, it is technically difficult and not accurate unless the positioning of the transducer
is exact. Regardless, head of bed elevation is indicated for this patient. - CORRECT ANSWERS
The nurse is caring for a mechanically ventilated patient with a pulmonary artery catheter
who is receiving continuous enteral tube feedings. When obtaining continuous
hemodynamic monitoring measurements, what is the best nursing action?
a.
Do not document hemodynamic values until the patient can be placed in the supine
position.
b.
Level and zero reference the air-fluid interface of the transducer with the patient in the
supine position and record hemodynamic values.
c.
Level and zero reference the air-fluid interface of the transducer with the patient's head of
bed elevated to 30 degrees and record hemodynamic values.
d.
Level and zero reference the air-fluid interface of the transducer with the patient supine in
the side-lying position and record hemodynamic values.
ANS: B
A pulmonary artery catheter provides hemodynamic measurements that guide interventions
that include appropriate fluid therapy. Even though a pulmonary catheter provides multiple
intravenous access sites, this is not the primary purpose of the catheter. Although the
catheter is positioned in the pulmonary artery, positioning is not the purpose of the
catheter. The primary purpose of the catheter is not to aid in the healing of the heart but to
guide therapy. - CORRECT ANSWERS The nurse is educating a patient's family member
about a pulmonary artery catheter (PAC). Which statement by the family member best
indicates understanding of the purpose of the PAC?
a.
"The catheter will provide multiple sites to give intravenous fluid."
b.
"The catheter will allow the physician to better manage fluid therapy."
dr.j
QUESTIONS AND ANSWERS UPDATE 2024/2025 ALL ANSWERS 100%
CORRECT VERIFIED BEST EXAM SOLUTION RATED A+ FOR SUCCESS
Begin a dobutamine (Dobutrex) infusion.
d.
Obtain stat cardiac enzymes and troponin.
ANS: B
Numbness and tingling in the left hand, which is the location of an arterial catheter, indicates
possible neurovascular compromise and requires immediate action. A dampened waveform
can indicate problems with arterial line patency but is not an emergent situation. Slight
bloody drainage at the subclavian insertion site is not an unusual finding. Slight redness at
the insertion site, while of concern, does not require immediate action. - CORRECT
ANSWERS The nurse is caring for a patient with a left subclavian central venous catheter
(CVC) and a left radial arterial line. Which assessment finding by the nurse requires
immediate action?
a.
A dampened arterial line waveform
b.
Numbness and tingling in the left hand
c.
Slight bloody drainage at subclavian insertion site
d.
Slight redness at subclavian insertion site
ANS: B
Upon removal of an invasive arterial line, adequate pressure must be applied for at least 5
minutes to ensure adequate hemostasis. Application of an air occlusion dressing is not
standard of care following removal of an arterial line. Elevation of the affected limb following
removal of an arterial line is not a necessary intervention. Neutral wrist position is optimum
while the catheter is in place and not necessary after catheter discontinuation. - CORRECT
ANSWERS The physician writes an order to discontinue a patient's left radial arterial line.
When discontinuing the patient's invasive line, what is the priority nursing action?
a.
Apply an air occlusion dressing to insertion site.
b.
Apply pressure to the insertion site for 5 minutes.
dr.j
,TEST BANK QUESTIONS: CRITICAL EXAM 3 AND FINAL EXAM
QUESTIONS AND ANSWERS UPDATE 2024/2025 ALL ANSWERS 100%
CORRECT VERIFIED BEST EXAM SOLUTION RATED A+ FOR SUCCESS
c.
Elevate the affected limb on pillows for 24 hours.
d.
Keep the patient's wrist in a neutral position.
ANS: C
X-ray results indicate proper position of the catheter. The tip of the central venous catheter
should rest just above the right atrium in the superior vena cava. The central venous
catheter is positioned correctly in the superior vena cava. Dysrhythmias occur if the catheter
migrates to the right ventricle. Central venous catheters are placed into great vessels of the
venous system and not advanced into the pulmonary artery. - CORRECT ANSWERS
Following insertion of a central venous catheter, the nurse obtains a stat chest x-ray film to
verify proper catheter placement. The radiologist reports to the nurse: "The tip of the
catheter is located in the superior vena cava." What is the best interpretation of these
results by the nurse?
a.
The catheter is not positioned correctly and should be removed.
b.
The catheter position increases the risk of ventricular dysrhythmias.
c.
The distal tip of the catheter is in the appropriate position.
d.
The physician should be called to advance the catheter into the pulmonary artery.
ANS: C
Balloon inflation should never be forced because the PAC may have migrated further into the
pulmonary artery, creating resistance to balloon inflation. Verification of proper line
placement is warranted to avoid pulmonary artery rupture. In addition, the PAC waveform
should be observed to assist in identifying location of the tip of the PAC. In this scenario,
adding additional air to the balloon will further risk pulmonary artery rupture.
Advancing a pulmonary artery catheter is not within the nurse's scope of practice.
Flushing the distal port with saline may be indicated to ensure patency; however, the
balloon of the PAC should never be locked in the inflated position as rupture of the
pulmonary artery may occur. - CORRECT ANSWERS 10. While inflating the balloon of a
dr.j
,TEST BANK QUESTIONS: CRITICAL EXAM 3 AND FINAL EXAM
QUESTIONS AND ANSWERS UPDATE 2024/2025 ALL ANSWERS 100%
CORRECT VERIFIED BEST EXAM SOLUTION RATED A+ FOR SUCCESS
pulmonary artery catheter (PAC) with 1.0 mL of air to obtain a pulmonary artery occlusion
pressure (PAOP), the nurse encounters resistance. What is the best nursing action?
a.
Add an additional 0.5 mL of air to the balloon and repeat the procedure.
b.
Advance the catheter with the balloon deflated and repeat the procedure.
c.
Deflate the balloon and obtain a chest x-ray study to determine line placement.
d.
Lock the balloon in the inflated position and flush the distal port of the PAC with normal
saline.
ANS: A
Diminished breaths sounds over the lung field on the same side of the line insertion site may
be indicative of a pneumothorax. A pneumothorax, which can develop slowly, is a major
complication following insertion of central lines when the subclavian route is used. Localized
pain at catheter insertion site is not the immediate priority in this scenario. A measured
central venous pressure of 5 mm Hg is normal. Slight bloody drainage at the insertion site
soon after the procedure does not require immediate action. - CORRECT ANSWERS The
nurse is caring for a patient following insertion of a left subclavian central venous catheter
(CVC). Which assessment finding 2 hours after insertion by the nurse warrants immediate
action?
a.
Diminished breath sounds over left lung field
b.
Localized pain at catheter insertion site
c.
Measured central venous pressure of 5 mm Hg
d.
Slight bloody drainage around insertion site
ANS: C
Elevation of the head of bed is an important intervention to prevent aspiration and
ventilator-associated pneumonia. Patients who require hemodynamic monitoring while
dr.j
, TEST BANK QUESTIONS: CRITICAL EXAM 3 AND FINAL EXAM
QUESTIONS AND ANSWERS UPDATE 2024/2025 ALL ANSWERS 100%
CORRECT VERIFIED BEST EXAM SOLUTION RATED A+ FOR SUCCESS
receiving tube feedings should have the air-fluid interface of the transducer leveled with the
phlebostatic axis while the head of bed is elevated to at least 30 degrees. Readings will be
accurate. Supine positioning of a mechanically ventilated patient increases the risk of
aspiration and ventilator-associated pneumonia and is contraindicated in this patient.
Hemodynamic values can be accurately measured and trended in with the head of the bed
elevated as high as 60 degrees. Even though hemodynamic values can be obtained in lateral
positions, it is technically difficult and not accurate unless the positioning of the transducer
is exact. Regardless, head of bed elevation is indicated for this patient. - CORRECT ANSWERS
The nurse is caring for a mechanically ventilated patient with a pulmonary artery catheter
who is receiving continuous enteral tube feedings. When obtaining continuous
hemodynamic monitoring measurements, what is the best nursing action?
a.
Do not document hemodynamic values until the patient can be placed in the supine
position.
b.
Level and zero reference the air-fluid interface of the transducer with the patient in the
supine position and record hemodynamic values.
c.
Level and zero reference the air-fluid interface of the transducer with the patient's head of
bed elevated to 30 degrees and record hemodynamic values.
d.
Level and zero reference the air-fluid interface of the transducer with the patient supine in
the side-lying position and record hemodynamic values.
ANS: B
A pulmonary artery catheter provides hemodynamic measurements that guide interventions
that include appropriate fluid therapy. Even though a pulmonary catheter provides multiple
intravenous access sites, this is not the primary purpose of the catheter. Although the
catheter is positioned in the pulmonary artery, positioning is not the purpose of the
catheter. The primary purpose of the catheter is not to aid in the healing of the heart but to
guide therapy. - CORRECT ANSWERS The nurse is educating a patient's family member
about a pulmonary artery catheter (PAC). Which statement by the family member best
indicates understanding of the purpose of the PAC?
a.
"The catheter will provide multiple sites to give intravenous fluid."
b.
"The catheter will allow the physician to better manage fluid therapy."
dr.j
