NCLEX MACHINAL VENT QUIZLET QUESTION & ANSWERS
. Which action will the nurse need to do when preparing to assist with the
insertion of a pulmonary artery catheter?
a. Determine if the cardiac troponin level is elevated.
b. Auscultate heart and breath sounds during insertion.
c. Place the patient on NPO status before the procedure.
d. Attach cardiac monitoring leads before the procedure.
ANS: D
Dysrhythmias can occur as the catheter is floated through the right atrium and
ventricle, and it is important for the nurse to monitor for these during insertion.
Pulmonary artery catheter insertion does not require anesthesia, and the patient
will not need to be NPO. Changes in cardiac troponin or heart and breath sounds
are not expected during pulmonary artery catheter insertion.
10. When assisting with the placement of a pulmonary artery (PA) catheter, the
nurse notes that the catheter is correctly placed when the monitor shows a
a. typical PA pressure waveform.
b. tracing of the systemic arterial pressure.
c. tracing of the systemic vascular resistance.
d. typical PA wedge pressure (PAWP) tracing.
ANS: D
The purpose of a PA line is to measure PAWP, so the catheter is floated through
the pulmonary artery until the dilated balloon wedges in a distal branch of the
pulmonary artery, and the PAWP readings are available. After insertion, the
balloon is deflated and the PA waveform will be observed. Systemic arterial
pressures are obtained using an arterial line and the systemic vascular resistance
is a calculated value, not a waveform.
A patient is placed under the care of a nurse. The nurse notices that his
ScvO2/SvO2 has increased. What does this usually indicate? Select all that apply:
1. Stroke
2. Improved perfusion
3 Occlusion of the catheter
4 Decreased metabolic rate
5 Increased arterial oxygen saturation
,2, 4, 5
Increased ScvO2/SvO2 is clinically significant and may indicate a clinical
improvement in terms of increased arterial oxygen saturation, improved
perfusion, and decreased metabolic rate. It may also indicate problems like sepsis.
In sepsis, oxygen is not extracted properly at the tissue level, resulting in
increased ScvO2/SvO2. Stroke or occlusion of the catheter does not increase the
ScvO2/SvO2.
A patient is placed on mechanical ventilation. A nurse notices that the alarm for
the high-pressure limit has been set off. What are the possible conditions that
could give rise to this alarm? Select all that apply.
1 Over sedation
2 Secretions, coughing, or gagging
3 Loss of airway through total or partial extubation
4 Patient fighting ventilator
5 Decreased compliance due to pulmonary edema
6 kinked or compressed tubing
2, 4,5, 6
The possible causes for high-pressure limit alarm to go off include secretions,
coughing, or gagging. It may also be set off in case of ventilator asynchrony if the
patient is fighting the ventilator. Decreased compliance due to conditions like
pulmonary edema may also cause the setting off of the high-pressure alarm. It can
also be due to kinked or compressed tubing, which usually happens when the
patient is biting on the endotracheal tube. Over sedation and loss of airway cause
an apnea alarm and can also set off the low-pressure limit alarm.
8. Which action is a priority for the nurse to take when the low pressure alarm
sounds for a patient who has an arterial line in the left radial artery?
a. Fast flush the arterial line.
b. Check the left hand for pallor.
c. Assess for cardiac dysrhythmias.
d. Rezero the monitoring equipment.
ANS: C
The low pressure alarm indicates a drop in the patient's blood pressure, which
may be caused by cardiac dysrhythmias. There is no indication to rezero the
,equipment. Pallor of the left hand would be caused by occlusion of the radial
artery by the arterial catheter, not by low pressure. There is no indication of a
need for flushing the line.
10. When assisting with the placement of a pulmonary artery (PA) catheter, the
nurse notes that the catheter is correctly placed when the monitor shows a
a. typical PA pressure waveform.
b. tracing of the systemic arterial pressure.
c. tracing of the systemic vascular resistance.
d. typical PA wedge pressure (PAWP) tracing.
ANS: D
The purpose of a PA line is to measure PAWP, so the catheter is floated through
the pulmonary artery until the dilated balloon wedges in a distal branch of the
pulmonary artery, and the PAWP readings are available. After insertion, the
balloon is deflated and the PA waveform will be observed. Systemic arterial
pressures are obtained using an arterial line and the systemic vascular resistance
is a calculated value, not a waveform.
9. Which action will the nurse need to do when preparing to assist with the
insertion of a pulmonary artery catheter?
a. Determine if the cardiac troponin level is elevated.
b. Auscultate heart and breath sounds during insertion.
c. Place the patient on NPO status before the procedure.
d. Attach cardiac monitoring leads before the procedure.
ANS: D
Dysrhythmias can occur as the catheter is floated through the right atrium and
ventricle, and it is important for the nurse to monitor for these during insertion.
Pulmonary artery catheter insertion does not require anesthesia, and the patient
will not need to be NPO. Changes in cardiac troponin or heart and breath sounds
are not expected during pulmonary artery catheter insertion.
6. The intensive care unit (ICU) nurse educator will determine that teaching about
arterial pressure monitoring for a new staff nurse has been effective when the
nurse
a. balances and calibrates the monitoring equipment every 2 hours.
b. positions the zero-reference stopcock line level with the phlebostatic axis.
c. ensures that the patient is supine with the head of the bed flat for all readings.
, d. rechecks the location of the phlebostatic axis when changing the patient's
position.
ANS: B
For accurate measurement of pressures, the zero-reference level should be at the
phlebostatic axis. There is no need to rebalance and recalibrate monitoring
equipment hourly. Accurate hemodynamic readings are possible with the
patient's head raised to 45 degrees or in the prone position. The anatomic
position of the phlebostatic axis does not change when patients are repositioned.
4. Following surgery for an abdominal aortic aneurysm, a patient's central venous
pressure (CVP) monitor indicates low pressures. Which action is a priority for the
nurse to take?
a. Administer IV diuretic medications.
b. Increase the IV fluid infusion per protocol.
c. Document the CVP and continue to monitor.
d. Elevate the head of the patient's bed to 45 degrees.
ANS: B
A low CVP indicates hypovolemia and a need for an increase in the infusion rate.
Diuretic administration will contribute to hypovolemia and elevation of the head
may decrease cerebral perfusion. Documentation and continued monitoring is an
inadequate response to the low CVP.
12. The central venous oxygen saturation (ScvO2) is decreasing in a patient who
has severe pancreatitis. To determine the possible cause of the decreased ScvO2,
the nurse assesses the patient's
a. lipase.
b. temperature.
c. urinary output.
d. body mass index.
ANS: B
Elevated temperature increases metabolic demands and oxygen use by tissues,
resulting in a drop in oxygen saturation of central venous blood. Information
about the patient's body mass index, urinary output, and lipase will not help in
determining the cause of the patient's drop in ScvO2.
22. A comatose patient with a possible cervical spine injury is intubated with a
nasal endotracheal (ET) tube. The nurse
. Which action will the nurse need to do when preparing to assist with the
insertion of a pulmonary artery catheter?
a. Determine if the cardiac troponin level is elevated.
b. Auscultate heart and breath sounds during insertion.
c. Place the patient on NPO status before the procedure.
d. Attach cardiac monitoring leads before the procedure.
ANS: D
Dysrhythmias can occur as the catheter is floated through the right atrium and
ventricle, and it is important for the nurse to monitor for these during insertion.
Pulmonary artery catheter insertion does not require anesthesia, and the patient
will not need to be NPO. Changes in cardiac troponin or heart and breath sounds
are not expected during pulmonary artery catheter insertion.
10. When assisting with the placement of a pulmonary artery (PA) catheter, the
nurse notes that the catheter is correctly placed when the monitor shows a
a. typical PA pressure waveform.
b. tracing of the systemic arterial pressure.
c. tracing of the systemic vascular resistance.
d. typical PA wedge pressure (PAWP) tracing.
ANS: D
The purpose of a PA line is to measure PAWP, so the catheter is floated through
the pulmonary artery until the dilated balloon wedges in a distal branch of the
pulmonary artery, and the PAWP readings are available. After insertion, the
balloon is deflated and the PA waveform will be observed. Systemic arterial
pressures are obtained using an arterial line and the systemic vascular resistance
is a calculated value, not a waveform.
A patient is placed under the care of a nurse. The nurse notices that his
ScvO2/SvO2 has increased. What does this usually indicate? Select all that apply:
1. Stroke
2. Improved perfusion
3 Occlusion of the catheter
4 Decreased metabolic rate
5 Increased arterial oxygen saturation
,2, 4, 5
Increased ScvO2/SvO2 is clinically significant and may indicate a clinical
improvement in terms of increased arterial oxygen saturation, improved
perfusion, and decreased metabolic rate. It may also indicate problems like sepsis.
In sepsis, oxygen is not extracted properly at the tissue level, resulting in
increased ScvO2/SvO2. Stroke or occlusion of the catheter does not increase the
ScvO2/SvO2.
A patient is placed on mechanical ventilation. A nurse notices that the alarm for
the high-pressure limit has been set off. What are the possible conditions that
could give rise to this alarm? Select all that apply.
1 Over sedation
2 Secretions, coughing, or gagging
3 Loss of airway through total or partial extubation
4 Patient fighting ventilator
5 Decreased compliance due to pulmonary edema
6 kinked or compressed tubing
2, 4,5, 6
The possible causes for high-pressure limit alarm to go off include secretions,
coughing, or gagging. It may also be set off in case of ventilator asynchrony if the
patient is fighting the ventilator. Decreased compliance due to conditions like
pulmonary edema may also cause the setting off of the high-pressure alarm. It can
also be due to kinked or compressed tubing, which usually happens when the
patient is biting on the endotracheal tube. Over sedation and loss of airway cause
an apnea alarm and can also set off the low-pressure limit alarm.
8. Which action is a priority for the nurse to take when the low pressure alarm
sounds for a patient who has an arterial line in the left radial artery?
a. Fast flush the arterial line.
b. Check the left hand for pallor.
c. Assess for cardiac dysrhythmias.
d. Rezero the monitoring equipment.
ANS: C
The low pressure alarm indicates a drop in the patient's blood pressure, which
may be caused by cardiac dysrhythmias. There is no indication to rezero the
,equipment. Pallor of the left hand would be caused by occlusion of the radial
artery by the arterial catheter, not by low pressure. There is no indication of a
need for flushing the line.
10. When assisting with the placement of a pulmonary artery (PA) catheter, the
nurse notes that the catheter is correctly placed when the monitor shows a
a. typical PA pressure waveform.
b. tracing of the systemic arterial pressure.
c. tracing of the systemic vascular resistance.
d. typical PA wedge pressure (PAWP) tracing.
ANS: D
The purpose of a PA line is to measure PAWP, so the catheter is floated through
the pulmonary artery until the dilated balloon wedges in a distal branch of the
pulmonary artery, and the PAWP readings are available. After insertion, the
balloon is deflated and the PA waveform will be observed. Systemic arterial
pressures are obtained using an arterial line and the systemic vascular resistance
is a calculated value, not a waveform.
9. Which action will the nurse need to do when preparing to assist with the
insertion of a pulmonary artery catheter?
a. Determine if the cardiac troponin level is elevated.
b. Auscultate heart and breath sounds during insertion.
c. Place the patient on NPO status before the procedure.
d. Attach cardiac monitoring leads before the procedure.
ANS: D
Dysrhythmias can occur as the catheter is floated through the right atrium and
ventricle, and it is important for the nurse to monitor for these during insertion.
Pulmonary artery catheter insertion does not require anesthesia, and the patient
will not need to be NPO. Changes in cardiac troponin or heart and breath sounds
are not expected during pulmonary artery catheter insertion.
6. The intensive care unit (ICU) nurse educator will determine that teaching about
arterial pressure monitoring for a new staff nurse has been effective when the
nurse
a. balances and calibrates the monitoring equipment every 2 hours.
b. positions the zero-reference stopcock line level with the phlebostatic axis.
c. ensures that the patient is supine with the head of the bed flat for all readings.
, d. rechecks the location of the phlebostatic axis when changing the patient's
position.
ANS: B
For accurate measurement of pressures, the zero-reference level should be at the
phlebostatic axis. There is no need to rebalance and recalibrate monitoring
equipment hourly. Accurate hemodynamic readings are possible with the
patient's head raised to 45 degrees or in the prone position. The anatomic
position of the phlebostatic axis does not change when patients are repositioned.
4. Following surgery for an abdominal aortic aneurysm, a patient's central venous
pressure (CVP) monitor indicates low pressures. Which action is a priority for the
nurse to take?
a. Administer IV diuretic medications.
b. Increase the IV fluid infusion per protocol.
c. Document the CVP and continue to monitor.
d. Elevate the head of the patient's bed to 45 degrees.
ANS: B
A low CVP indicates hypovolemia and a need for an increase in the infusion rate.
Diuretic administration will contribute to hypovolemia and elevation of the head
may decrease cerebral perfusion. Documentation and continued monitoring is an
inadequate response to the low CVP.
12. The central venous oxygen saturation (ScvO2) is decreasing in a patient who
has severe pancreatitis. To determine the possible cause of the decreased ScvO2,
the nurse assesses the patient's
a. lipase.
b. temperature.
c. urinary output.
d. body mass index.
ANS: B
Elevated temperature increases metabolic demands and oxygen use by tissues,
resulting in a drop in oxygen saturation of central venous blood. Information
about the patient's body mass index, urinary output, and lipase will not help in
determining the cause of the patient's drop in ScvO2.
22. A comatose patient with a possible cervical spine injury is intubated with a
nasal endotracheal (ET) tube. The nurse
