Chapter 08: Hemodynamic Monitoring
1. The nurse is caring for a 100-kg patient being monitored with a pulmonary artery catheter. The nurse assesses a blood pressure of 90/60 mm Hg, heart
rate 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation.
Which hemodynamic value requires immediate action by the nurse?
a. Cardiac index (CI) of 1.2 L/min/m3
b. Cardiac output (CO) of 4 L/min
c. Pulmonary vascular resistance (PVR) of 80 dynes/sec/cm–5
d. Systemic vascular resistance (SVR) of 1400 dynes/sec/cm–5
A cardiac index of 1.2 L/min/m3 combined with the identified clinical assessment findings indicate a low cardiac output with fluid overload (bilateral
crackles), requiring intervention. The remaining hemodynamic values are within normal limits: cardiac output of 4 L/min; pulmonary vascular resistance
of 80 dynes/sec/cm–5; and the systemic vascular resistance of 1400 dynes/sec/cm–5.
2. While caring for a patient with a small bowel obstruction, the nurse assesses a pulmonary artery occlusion pressure (PAOP) of 1 mm Hg and hourly
urine output of 5 mL. The nurse anticipates which therapeutic intervention?
a. Diuretics
b. Intravenous fluids
c. Negative inotropic agents
d. Vasopressors
Low pulmonary artery occlusion pressures usually indicate volume depletion, so intravenous fluids would be indicated. A normal hourly urine
output is 1 mL/kg or at least 30 mL/hour, so this is another indication that the patient is volume depleted. Administration of diuretics would worsen the
patient’s volume status. Negative inotropes would not improve the patient’s volume status. Vasopressors will increase blood pressure but are
contraindicated in a low volume state.
3. The nurse is caring for a patient who has had an arterial line inserted. To reduce the risk of complications, what is the priority nursing intervention?
a. Apply a pressure dressing to the insertion site.
b. Ensure that all tubing connections are tightened.
c. Obtain a portable x-ray to confirm placement.
d. Restrain the affected extremity for 24 hours.
Loose connections in hemodynamic monitoring tubing can lead to hemorrhage, a major complication of arterial pressure monitoring. Application of a
pressure dressing is required only upon arterial line removal. Blood return is adequate confirmation of arterial line placement; radiography is not
performed to confirm arterial line placement. Neutral positioning of the extremity and use of an arm board, without limb restraint, is the standard of care.
4. While caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary artery occlusion pressure (PAOP) 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?
a. Increase supplemental oxygen and notify respiratory therapy.
b. Notify the provider immediately of the assessment findings.
c. Obtain a stat chest x-ray film to verify proper catheter placement.
d. Zero reference and level the catheter at the phlebostatic axis.
A hemodynamic value not supported by clinical assessment should be treated as questionable. To ensure the accuracy of hemodynamic readings, the
catheter transducer system must be leveled at the phlebostatic axis and zero referenced. In this example, the catheter transducer system may be
lower than the phlebostatic axis, resulting in erroneously higher pressures. Clinical manifestations do not support increasing supplemental
oxygen. Clinical manifestations do not warrant provider intervention; aberrant values should be investigated further. An aberrant value warrants further
investigation, which includes zero referencing and checking the level as an initial measure. A chest x-ray study is not warranted at this time.
5. A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135
beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vascular resistance of 3000 dynes/sec/cm –5, and a hematocrit of 20%.
The nurse anticipates administration of which the following therapies or medications?
a. Blood transfusion
b. Furosemide
c. Dobutamine infusion
d. Dopamine hydrochloride infusion
Both hemodynamic parameters and the reported hematocrit value indicate hypovolemia and blood loss requiring volume resuscitation with blood
products. Furosemide administration will worsen fluid volume status. Inotropic agents will not correct the underlying fluid volume deficit and anemia.
Vasoconstrictors are contraindicated in a volume-depleted state.
6. After pulmonary artery catheter insertion, the nurse assesses a pulmonary artery pressure of 45/25 mm Hg, a pulmonary artery occlusion pressure
(PAOP) of 20 mm Hg, a cardiac output of 2.6 L/min and a cardiac index of 1.9 L/min/m2. Which provider order is of the highest priority?
a. Apply 50% oxygen via Venturi mask.
b. Insert an indwelling urinary catheter.
c. Begin a dobutamine infusion.
, d. Obtain stat cardiac enzymes and troponin.
The pulmonary pressures are higher than normal, indicating elevated preload, and the cardiac index and output values are low. The priority order for the
nurse to implement is to begin a dobutamine infusion to improve cardiac output, possibly reducing pulmonary artery occlusion pressures. The other
treatments may be important, depending on other patient data, but the dobutamine infusion is the most important at this time.
7. 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
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.
8. The provider 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.
c. Elevate the affected limb on pillows for 24 hours.
d. Keep the patient’s wrist in a neutral position.
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 the 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 but unnecessary after catheter discontinuation.
9. 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.
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.
10. While inflating the balloon of a 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.
Balloon inflation should never be forced because the PAC may have migrated farther 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.
11. 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
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.
12. 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
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.
Elevation of the head of bed is an important intervention to prevent aspiration and ventilator-associated pneumonia. Patients who require
hemodynamic monitoring while 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 aspiration of tube feeding, 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.
13. 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 provider to better manage fluid therapy.”
c. “The catheter tip comes to rest inside my brother’s pulmonary artery.”
d. “The catheter will be in position until the heart has a chance to heal.”
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.
14. The nurse is preparing to obtain a pulmonary artery occlusion pressure (PAOP) reading for a patient who is mechanically ventilated. Ensuring that the
air-fluid interface is at the level of the phlebostatic axis, what is the best nursing action?
a. Place the patient in the supine position and record the PAOP immediately after exhalation.
b. Place the patient in the supine position and document the average PAOP obtained after three measurements.
c. Place the patient with the head of bed elevated 30 degrees and document the average PAOP pressure obtained.
d. Place the patient with the head of bed elevated 30 degrees and record the PAOP just before the increase in pressures during inhalation.
Pressures are highest when measured at end exhalation in the spontaneously breathing patient. In mechanically ventilated patients, pressures
increase with inhalation and decrease with exhalation. Measurements are obtained just before the increase in pressure during inhalation. Supine
positioning is contraindicated in the mechanically ventilated patient. The head of bed should be elevated to 30 degrees. Pulmonary artery occlusion
pressure is not averaged, but measured during inhalation in the mechanically ventilated patient while appropriate positioning is maintained.
15. The charge nurse is supervising care for a group of patients monitored with a variety of invasive hemodynamic devices. Which patient should the charge
nurse evaluate first?
a. A patient with a central venous pressure (RAP/CVP) of 6 mm Hg and 40 mL of urine output in the past hour
b. A patient with a left radial arterial line with a BP of 110/60 mm Hg and slightly dampened arterial waveform
c. A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula
d. A patient with a pulmonary artery pressure of 25/10 mm Hg and an oxygen saturation of 94% on 2 L of oxygen via nasal cannula
A high pulmonary artery occlusion pressure of 25 mm Hg combined with low oxygen saturation is indicative of fluid volume overload and
warrants priority action because the patient is at risk for hypoxemia. A CVP of 6 mm Hg and 40 mL of hourly urine output are acceptable
assessment findings. A patient with a normal blood pressure and with a slightly dampened waveform does not require immediate action. A pulmonary
artery pressure of 25/10 mm Hg and a normal oxygen saturation does not require immediate treatment.
16. The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best reduces the risk of
catheter-related bloodstream infection (CRBSI)?
a. Review daily the necessity of the central venous catheter.
b. Cleanse the insertion site daily with isopropyl alcohol.
c. Change the pressurized tubing system and flush bag daily.
d. Maintain a pressure of 300 mm Hg on the flush bag.
Duration of the catheter is an independent risk factor for CRBSI, and removal of the catheter when not needed to guide treatment is associated with a
reduction in mortality. Cleansing the insertion site should be guided by institutional guidelines and is best accomplished with chlorhexidine skin
antisepsis. Minimizing the number of times the flush system is opened by changing tubing no more frequently than every 72 to 96 hours reduces the risk
of CRBSI. Maintaining a pressure of 300 mm Hg on the flush solution bag helps maintain the integrity of the invasive line but does not reduce the risk of
infection.
17. During insertion of a pulmonary artery catheter, the provider asks the nurse to assist by inflating the balloon with 1.5 mL of air. As the provider advances
the catheter, the nurse notices premature ventricular contractions on the monitor. What is the best action by the nurse?
a. Deflate the balloon while slowly withdrawing the catheter.
b. Instruct the patient to cough and deep-breathe forcefully.
c. Inflate the catheter balloon with an additional 1 mL of air.
d. Ensure lidocaine hydrochloride (IV) is immediately available.
During the insertion of the pulmonary artery catheter, ventricular dysrhythmias may occur as the catheter passes through the right ventricle. Treatment
with lidocaine hydrochloride (or amiodarone) may be necessary to suppress the irritated ventricle and should be readily available. Withdrawal
, of the catheter is not within the scope of practice of the nurse and may not be necessary. Having the patient cough and deep-breathe will not correct the
problem. The maximum volume of air necessary to inflate the balloon is 1.5 mL. Any additional volumes added may increase the risk of complications.
18. Following insertion of a pulmonary artery catheter (PAC), the provider requests the nurse obtain a blood sample for mixed venous oxygen saturation
(SvO2). Which action by the nurse best ensures the obtained value is accurate?
a. Zero referencing the transducer at the level of the phlebostatic axis following insertion
b. Calibrating the system with a central venous blood sample and arterial blood gas value
c. Ensuring patency of the catheter using a 0.9% normal saline solution pressurized at 300 mm Hg
d. Using noncompliant pressure tubing that is no longer than 36 to 48 inches and has minimal stopcocks
To ensure that an accurate SvO2 is obtained, calibration of the invasive monitoring system (e.g., PAC) is accomplished upon insertion and requires both
a central venous blood sample from the PAC and an arterial blood gas sample. This process is unique to the accuracy of venous oxygen saturation
monitoring systems. Zero referencing the transducer at the level of the phlebostatic axis, ensuring patency of the catheter with a pressurized flush
system, and using tubing of adequate length ensure accuracy of all hemodynamic monitoring systems.
19. The nurse is caring for a 70-kg patient in septic shock with a pulmonary artery catheter. Which hemodynamic value indicates an appropriate response to
therapy aimed at enhancing oxygen delivery to the organs and tissues?
a. Arterial lactate level of 1.0 mEq/L
b. Cardiac output of 2.5 L/min
c. Mixed venous (SvO2) of 40%
d. Cardiac index of 1.5 L/min/m2
An arterial lactate level of 1.0 mEq/L is within normal limits and is indicative of normal oxygen delivery to the tissues. The cardiac output, mixed venous
saturation, and cardiac index values are all below normal limits, indicating inadequate cardiac output sufficient to provide oxygen delivery to the organs
and tissues.
20. The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 125
beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO2) of 90% on a 50% Venturi mask. Hemodynamic values include a cardiac
output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pressure (PAOP) of 3 mm Hg. The nurse
questions which of the following physician’s orders?
a. Titrate supplemental oxygen to achieve a SpO2 94%.
b. Infuse 500 mL 0.9% normal saline over 1 hour.
c. Obtain arterial blood gas and serum electrolytes.
d. Administer furosemide (Lasix) 20 mg intravenously.
A central venous pressure of 1 mm Hg, pulmonary artery occlusion pressure of 3 mm Hg along with a blood pressure of 85/40 mm Hg and heart rate of
125 are indicative of a low volume state. Infusion of 500 mL of 0.9% normal saline will increase circulating fluid volume. Administration of furosemide
(Lasix) is contraindicated and could further reduce circulating fluid volume. Titrating supplemental oxygen and obtaining serum blood gas and electrolyte
samples, although not a priority, are appropriate interventions.
21. The charge nurse has a pulse contour cardiac output monitoring system available for use in the surgical intensive care unit. For which patient is use of
this device most appropriate?
a. A patient with a history of aortic insufficiency admitted with a postoperative myocardial infarction
b. A mechanically ventilated patient with cardiogenic shock being treated with an intraaortic balloon pump
c. A patient with a history of atrial fibrillation having frequent episodes of paroxysmal supraventricular tachycardia
d. A mechanically ventilated patient admitted following repair of an acute bowel obstruction
Pulse contour analysis systems provide stroke volume variation and pulse pressure variation data and are better predictors of fluid responsiveness
in mechanically ventilated patients. A patient postoperative from repair of an acute bowel obstruction that is mechanically ventilated is an appropriate
candidate for this method of monitoring. Aortic insufficiency, intraaortic balloon pump therapy, and the presence of cardiac dysrhythmias are conditions in
which pulse contour analysis systems are either inaccurate or contraindicated.
22. The provider prescribes a pulmonary artery occlusive pressure reading (PAOP) for a patient being monitored with a pulmonary artery catheter.
Immediately after obtaining an occlusive pressure, the nurse notes the change in waveform indicated on the strip below. What are the best actions by
the nurse?
a. Turn the patient to the left side; obtain a stat portable chest x-ray.
b. Place the patient supine; repeat zero referencing of the system.
c. Document the wedge pressure; continue to monitor the patient.
d. Perform an immediate dynamic response test; obtain a chest x-ray.
After obtaining a pulmonary artery occlusive pressure and deflating the balloon, the monitor tracing indicates the waveform has returned to a normal
pulmonary artery waveform. The nurse should document the occlusive value and continue to monitor the patient. Turning the patient to the left side, zero
referencing the system, and performing a dynamic response test are not necessary as the waveform displayed is normal.
23. The nurse is caring for a patient with an arterial monitoring system. The nurse assesses the patient’s noninvasive cuff blood pressure to be 70/40 mm
Hg. The arterial blood pressure measurement via an intraarterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What is the
best action by the nurse?
a. Activate the rapid response system.
1. The nurse is caring for a 100-kg patient being monitored with a pulmonary artery catheter. The nurse assesses a blood pressure of 90/60 mm Hg, heart
rate 110 beats/min, respirations 36/min, oxygen saturation of 89% on 3 L of oxygen via nasal cannula. Bilateral crackles are audible upon auscultation.
Which hemodynamic value requires immediate action by the nurse?
a. Cardiac index (CI) of 1.2 L/min/m3
b. Cardiac output (CO) of 4 L/min
c. Pulmonary vascular resistance (PVR) of 80 dynes/sec/cm–5
d. Systemic vascular resistance (SVR) of 1400 dynes/sec/cm–5
A cardiac index of 1.2 L/min/m3 combined with the identified clinical assessment findings indicate a low cardiac output with fluid overload (bilateral
crackles), requiring intervention. The remaining hemodynamic values are within normal limits: cardiac output of 4 L/min; pulmonary vascular resistance
of 80 dynes/sec/cm–5; and the systemic vascular resistance of 1400 dynes/sec/cm–5.
2. While caring for a patient with a small bowel obstruction, the nurse assesses a pulmonary artery occlusion pressure (PAOP) of 1 mm Hg and hourly
urine output of 5 mL. The nurse anticipates which therapeutic intervention?
a. Diuretics
b. Intravenous fluids
c. Negative inotropic agents
d. Vasopressors
Low pulmonary artery occlusion pressures usually indicate volume depletion, so intravenous fluids would be indicated. A normal hourly urine
output is 1 mL/kg or at least 30 mL/hour, so this is another indication that the patient is volume depleted. Administration of diuretics would worsen the
patient’s volume status. Negative inotropes would not improve the patient’s volume status. Vasopressors will increase blood pressure but are
contraindicated in a low volume state.
3. The nurse is caring for a patient who has had an arterial line inserted. To reduce the risk of complications, what is the priority nursing intervention?
a. Apply a pressure dressing to the insertion site.
b. Ensure that all tubing connections are tightened.
c. Obtain a portable x-ray to confirm placement.
d. Restrain the affected extremity for 24 hours.
Loose connections in hemodynamic monitoring tubing can lead to hemorrhage, a major complication of arterial pressure monitoring. Application of a
pressure dressing is required only upon arterial line removal. Blood return is adequate confirmation of arterial line placement; radiography is not
performed to confirm arterial line placement. Neutral positioning of the extremity and use of an arm board, without limb restraint, is the standard of care.
4. While caring for a patient with a pulmonary artery catheter, the nurse notes the pulmonary artery occlusion pressure (PAOP) 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?
a. Increase supplemental oxygen and notify respiratory therapy.
b. Notify the provider immediately of the assessment findings.
c. Obtain a stat chest x-ray film to verify proper catheter placement.
d. Zero reference and level the catheter at the phlebostatic axis.
A hemodynamic value not supported by clinical assessment should be treated as questionable. To ensure the accuracy of hemodynamic readings, the
catheter transducer system must be leveled at the phlebostatic axis and zero referenced. In this example, the catheter transducer system may be
lower than the phlebostatic axis, resulting in erroneously higher pressures. Clinical manifestations do not support increasing supplemental
oxygen. Clinical manifestations do not warrant provider intervention; aberrant values should be investigated further. An aberrant value warrants further
investigation, which includes zero referencing and checking the level as an initial measure. A chest x-ray study is not warranted at this time.
5. A patient is admitted to the hospital with multiple trauma and extensive blood loss. The nurse assesses vital signs to be BP 80/50 mm Hg, heart rate 135
beats/min, respirations 36 breaths/min, cardiac output (CO) of 2 L/min, systemic vascular resistance of 3000 dynes/sec/cm –5, and a hematocrit of 20%.
The nurse anticipates administration of which the following therapies or medications?
a. Blood transfusion
b. Furosemide
c. Dobutamine infusion
d. Dopamine hydrochloride infusion
Both hemodynamic parameters and the reported hematocrit value indicate hypovolemia and blood loss requiring volume resuscitation with blood
products. Furosemide administration will worsen fluid volume status. Inotropic agents will not correct the underlying fluid volume deficit and anemia.
Vasoconstrictors are contraindicated in a volume-depleted state.
6. After pulmonary artery catheter insertion, the nurse assesses a pulmonary artery pressure of 45/25 mm Hg, a pulmonary artery occlusion pressure
(PAOP) of 20 mm Hg, a cardiac output of 2.6 L/min and a cardiac index of 1.9 L/min/m2. Which provider order is of the highest priority?
a. Apply 50% oxygen via Venturi mask.
b. Insert an indwelling urinary catheter.
c. Begin a dobutamine infusion.
, d. Obtain stat cardiac enzymes and troponin.
The pulmonary pressures are higher than normal, indicating elevated preload, and the cardiac index and output values are low. The priority order for the
nurse to implement is to begin a dobutamine infusion to improve cardiac output, possibly reducing pulmonary artery occlusion pressures. The other
treatments may be important, depending on other patient data, but the dobutamine infusion is the most important at this time.
7. 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
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.
8. The provider 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.
c. Elevate the affected limb on pillows for 24 hours.
d. Keep the patient’s wrist in a neutral position.
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 the 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 but unnecessary after catheter discontinuation.
9. 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.
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.
10. While inflating the balloon of a 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.
Balloon inflation should never be forced because the PAC may have migrated farther 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.
11. 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
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.
12. 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
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.
Elevation of the head of bed is an important intervention to prevent aspiration and ventilator-associated pneumonia. Patients who require
hemodynamic monitoring while 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 aspiration of tube feeding, 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.
13. 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 provider to better manage fluid therapy.”
c. “The catheter tip comes to rest inside my brother’s pulmonary artery.”
d. “The catheter will be in position until the heart has a chance to heal.”
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.
14. The nurse is preparing to obtain a pulmonary artery occlusion pressure (PAOP) reading for a patient who is mechanically ventilated. Ensuring that the
air-fluid interface is at the level of the phlebostatic axis, what is the best nursing action?
a. Place the patient in the supine position and record the PAOP immediately after exhalation.
b. Place the patient in the supine position and document the average PAOP obtained after three measurements.
c. Place the patient with the head of bed elevated 30 degrees and document the average PAOP pressure obtained.
d. Place the patient with the head of bed elevated 30 degrees and record the PAOP just before the increase in pressures during inhalation.
Pressures are highest when measured at end exhalation in the spontaneously breathing patient. In mechanically ventilated patients, pressures
increase with inhalation and decrease with exhalation. Measurements are obtained just before the increase in pressure during inhalation. Supine
positioning is contraindicated in the mechanically ventilated patient. The head of bed should be elevated to 30 degrees. Pulmonary artery occlusion
pressure is not averaged, but measured during inhalation in the mechanically ventilated patient while appropriate positioning is maintained.
15. The charge nurse is supervising care for a group of patients monitored with a variety of invasive hemodynamic devices. Which patient should the charge
nurse evaluate first?
a. A patient with a central venous pressure (RAP/CVP) of 6 mm Hg and 40 mL of urine output in the past hour
b. A patient with a left radial arterial line with a BP of 110/60 mm Hg and slightly dampened arterial waveform
c. A patient with a pulmonary artery occlusion pressure of 25 mm Hg and an oxygen saturation of 89% on 3 L of oxygen via nasal cannula
d. A patient with a pulmonary artery pressure of 25/10 mm Hg and an oxygen saturation of 94% on 2 L of oxygen via nasal cannula
A high pulmonary artery occlusion pressure of 25 mm Hg combined with low oxygen saturation is indicative of fluid volume overload and
warrants priority action because the patient is at risk for hypoxemia. A CVP of 6 mm Hg and 40 mL of hourly urine output are acceptable
assessment findings. A patient with a normal blood pressure and with a slightly dampened waveform does not require immediate action. A pulmonary
artery pressure of 25/10 mm Hg and a normal oxygen saturation does not require immediate treatment.
16. The nurse is caring for a patient following insertion of a left subclavian central venous catheter (CVC). Which action by the nurse best reduces the risk of
catheter-related bloodstream infection (CRBSI)?
a. Review daily the necessity of the central venous catheter.
b. Cleanse the insertion site daily with isopropyl alcohol.
c. Change the pressurized tubing system and flush bag daily.
d. Maintain a pressure of 300 mm Hg on the flush bag.
Duration of the catheter is an independent risk factor for CRBSI, and removal of the catheter when not needed to guide treatment is associated with a
reduction in mortality. Cleansing the insertion site should be guided by institutional guidelines and is best accomplished with chlorhexidine skin
antisepsis. Minimizing the number of times the flush system is opened by changing tubing no more frequently than every 72 to 96 hours reduces the risk
of CRBSI. Maintaining a pressure of 300 mm Hg on the flush solution bag helps maintain the integrity of the invasive line but does not reduce the risk of
infection.
17. During insertion of a pulmonary artery catheter, the provider asks the nurse to assist by inflating the balloon with 1.5 mL of air. As the provider advances
the catheter, the nurse notices premature ventricular contractions on the monitor. What is the best action by the nurse?
a. Deflate the balloon while slowly withdrawing the catheter.
b. Instruct the patient to cough and deep-breathe forcefully.
c. Inflate the catheter balloon with an additional 1 mL of air.
d. Ensure lidocaine hydrochloride (IV) is immediately available.
During the insertion of the pulmonary artery catheter, ventricular dysrhythmias may occur as the catheter passes through the right ventricle. Treatment
with lidocaine hydrochloride (or amiodarone) may be necessary to suppress the irritated ventricle and should be readily available. Withdrawal
, of the catheter is not within the scope of practice of the nurse and may not be necessary. Having the patient cough and deep-breathe will not correct the
problem. The maximum volume of air necessary to inflate the balloon is 1.5 mL. Any additional volumes added may increase the risk of complications.
18. Following insertion of a pulmonary artery catheter (PAC), the provider requests the nurse obtain a blood sample for mixed venous oxygen saturation
(SvO2). Which action by the nurse best ensures the obtained value is accurate?
a. Zero referencing the transducer at the level of the phlebostatic axis following insertion
b. Calibrating the system with a central venous blood sample and arterial blood gas value
c. Ensuring patency of the catheter using a 0.9% normal saline solution pressurized at 300 mm Hg
d. Using noncompliant pressure tubing that is no longer than 36 to 48 inches and has minimal stopcocks
To ensure that an accurate SvO2 is obtained, calibration of the invasive monitoring system (e.g., PAC) is accomplished upon insertion and requires both
a central venous blood sample from the PAC and an arterial blood gas sample. This process is unique to the accuracy of venous oxygen saturation
monitoring systems. Zero referencing the transducer at the level of the phlebostatic axis, ensuring patency of the catheter with a pressurized flush
system, and using tubing of adequate length ensure accuracy of all hemodynamic monitoring systems.
19. The nurse is caring for a 70-kg patient in septic shock with a pulmonary artery catheter. Which hemodynamic value indicates an appropriate response to
therapy aimed at enhancing oxygen delivery to the organs and tissues?
a. Arterial lactate level of 1.0 mEq/L
b. Cardiac output of 2.5 L/min
c. Mixed venous (SvO2) of 40%
d. Cardiac index of 1.5 L/min/m2
An arterial lactate level of 1.0 mEq/L is within normal limits and is indicative of normal oxygen delivery to the tissues. The cardiac output, mixed venous
saturation, and cardiac index values are all below normal limits, indicating inadequate cardiac output sufficient to provide oxygen delivery to the organs
and tissues.
20. The nurse is caring for a patient with a pulmonary artery catheter. Assessment findings include a blood pressure of 85/40 mm Hg, heart rate of 125
beats/min, respiratory rate 35 breaths/min, and arterial oxygen saturation (SpO2) of 90% on a 50% Venturi mask. Hemodynamic values include a cardiac
output (CO) of 1.0 L/min, central venous pressure (CVP) of 1 mm Hg, and a pulmonary artery occlusion pressure (PAOP) of 3 mm Hg. The nurse
questions which of the following physician’s orders?
a. Titrate supplemental oxygen to achieve a SpO2 94%.
b. Infuse 500 mL 0.9% normal saline over 1 hour.
c. Obtain arterial blood gas and serum electrolytes.
d. Administer furosemide (Lasix) 20 mg intravenously.
A central venous pressure of 1 mm Hg, pulmonary artery occlusion pressure of 3 mm Hg along with a blood pressure of 85/40 mm Hg and heart rate of
125 are indicative of a low volume state. Infusion of 500 mL of 0.9% normal saline will increase circulating fluid volume. Administration of furosemide
(Lasix) is contraindicated and could further reduce circulating fluid volume. Titrating supplemental oxygen and obtaining serum blood gas and electrolyte
samples, although not a priority, are appropriate interventions.
21. The charge nurse has a pulse contour cardiac output monitoring system available for use in the surgical intensive care unit. For which patient is use of
this device most appropriate?
a. A patient with a history of aortic insufficiency admitted with a postoperative myocardial infarction
b. A mechanically ventilated patient with cardiogenic shock being treated with an intraaortic balloon pump
c. A patient with a history of atrial fibrillation having frequent episodes of paroxysmal supraventricular tachycardia
d. A mechanically ventilated patient admitted following repair of an acute bowel obstruction
Pulse contour analysis systems provide stroke volume variation and pulse pressure variation data and are better predictors of fluid responsiveness
in mechanically ventilated patients. A patient postoperative from repair of an acute bowel obstruction that is mechanically ventilated is an appropriate
candidate for this method of monitoring. Aortic insufficiency, intraaortic balloon pump therapy, and the presence of cardiac dysrhythmias are conditions in
which pulse contour analysis systems are either inaccurate or contraindicated.
22. The provider prescribes a pulmonary artery occlusive pressure reading (PAOP) for a patient being monitored with a pulmonary artery catheter.
Immediately after obtaining an occlusive pressure, the nurse notes the change in waveform indicated on the strip below. What are the best actions by
the nurse?
a. Turn the patient to the left side; obtain a stat portable chest x-ray.
b. Place the patient supine; repeat zero referencing of the system.
c. Document the wedge pressure; continue to monitor the patient.
d. Perform an immediate dynamic response test; obtain a chest x-ray.
After obtaining a pulmonary artery occlusive pressure and deflating the balloon, the monitor tracing indicates the waveform has returned to a normal
pulmonary artery waveform. The nurse should document the occlusive value and continue to monitor the patient. Turning the patient to the left side, zero
referencing the system, and performing a dynamic response test are not necessary as the waveform displayed is normal.
23. The nurse is caring for a patient with an arterial monitoring system. The nurse assesses the patient’s noninvasive cuff blood pressure to be 70/40 mm
Hg. The arterial blood pressure measurement via an intraarterial catheter in the same arm is assessed by the nurse to be 108/70 mm Hg. What is the
best action by the nurse?
a. Activate the rapid response system.
