High Acuity Exam 1 Questions
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1. The client with cirrhosis of the liver has signif- 3. Decreased preload from a relative vol-
icant ascites. The client is cold, clammy, and ume depletion
confused. The nurse interprets these findings
as indicating which physiological condition? 3. Ascites results in third-spacing of fluid
derived from the circulating blood vol-
1. Increased preload from increased venous ume. This is relative volume depletion,
return to the heart as the volume is still within the body
2. Decreased afterload from peripheral va- but no longer in the circulating volume.
sodilation Decreased preload results in decreased
3. Decreased preload from a relative volume cardiac output with resultant cold clam-
depletion my skin and decreased mentation.
4. Increased afterload from ankle edema
2. A client has had an arterial line inserted into 1. Regularly assess the color of the
the radial artery. Which nursing interventions client's hand.
should the nurse add to this client's plan of 2. Measure pulses distal to the insertion
care? (Select all that apply.) site.
4. Secure all line connections.
1. Regularly assess the color of the patient's 5. Observe insertion site for redness,
hand. warmth, or edema.
2. Measure pulses distal to the insertion site.
3. Remove the caps along the monitoring sys- 1. Insertion of an arterial line may dis-
tem. rupt distal blood flow. In this case this
4. Secure all line connections. disruption would affect the hand, so
5. Observe insertion site for redness, warmth, regular assessment of color is neces-
or edema. sary.
3) A patient has a PA catheter inserted. 2. Insertion of an arterial line may dis-
rupt distal blood flow. The nurse should
monitor pulses for this condition.
4. All line connections should be se-
cured to prevent accidental separation.
5. The insertion of an arterial catheter
, High Acuity Exam 1 Questions
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interrupts the skin, which is the body's
first line of defense against infection.
The site should be monitored for signs
of infection such as redness, warmth,
and edema.
3. A client has a PA catheter inserted. Which port 1. Proximal
should the nurse use for infusion of IV fluids?
1. Fluids can be infused through the
1. Proximal proximal lumen or into the right atrium.
2. Distal
3. Yellow port
4. Balloon port
4. The nurse has obtained a pulmonary wedge 4. Expel all air from the syringe and reat-
pressure (PAWP) from a PA catheter. What in- tach to the catheter.
terventions are necessary? (Select all that ap- 5. Leave the balloon deflated.
ply.)
4. Expelling the air and reattaching the
1. Manually deflate the balloon to assure all syringe helps to prevent accidental rein-
air is removed. flation of the balloon.
2. Tape the syringe used for inflation to the 5. The balloon should be left deflated to
head of the patient's allow for circulation distal to the balloon.
bed.
3. Leave the balloon inflated.
4. Expel all air from the syringe and reattach
to the catheter.
5. Leave the balloon deflated.
5. The nurse is preparing a client for insertion 2. "You will not feel the catheter as it is
of a pulmonary artery (PA) catheter. Which inserted."
information should the nurse provide?
2. The client will not feel the PA catheter
Study online at https://quizlet.com/_6vw62t
1. The client with cirrhosis of the liver has signif- 3. Decreased preload from a relative vol-
icant ascites. The client is cold, clammy, and ume depletion
confused. The nurse interprets these findings
as indicating which physiological condition? 3. Ascites results in third-spacing of fluid
derived from the circulating blood vol-
1. Increased preload from increased venous ume. This is relative volume depletion,
return to the heart as the volume is still within the body
2. Decreased afterload from peripheral va- but no longer in the circulating volume.
sodilation Decreased preload results in decreased
3. Decreased preload from a relative volume cardiac output with resultant cold clam-
depletion my skin and decreased mentation.
4. Increased afterload from ankle edema
2. A client has had an arterial line inserted into 1. Regularly assess the color of the
the radial artery. Which nursing interventions client's hand.
should the nurse add to this client's plan of 2. Measure pulses distal to the insertion
care? (Select all that apply.) site.
4. Secure all line connections.
1. Regularly assess the color of the patient's 5. Observe insertion site for redness,
hand. warmth, or edema.
2. Measure pulses distal to the insertion site.
3. Remove the caps along the monitoring sys- 1. Insertion of an arterial line may dis-
tem. rupt distal blood flow. In this case this
4. Secure all line connections. disruption would affect the hand, so
5. Observe insertion site for redness, warmth, regular assessment of color is neces-
or edema. sary.
3) A patient has a PA catheter inserted. 2. Insertion of an arterial line may dis-
rupt distal blood flow. The nurse should
monitor pulses for this condition.
4. All line connections should be se-
cured to prevent accidental separation.
5. The insertion of an arterial catheter
, High Acuity Exam 1 Questions
Study online at https://quizlet.com/_6vw62t
interrupts the skin, which is the body's
first line of defense against infection.
The site should be monitored for signs
of infection such as redness, warmth,
and edema.
3. A client has a PA catheter inserted. Which port 1. Proximal
should the nurse use for infusion of IV fluids?
1. Fluids can be infused through the
1. Proximal proximal lumen or into the right atrium.
2. Distal
3. Yellow port
4. Balloon port
4. The nurse has obtained a pulmonary wedge 4. Expel all air from the syringe and reat-
pressure (PAWP) from a PA catheter. What in- tach to the catheter.
terventions are necessary? (Select all that ap- 5. Leave the balloon deflated.
ply.)
4. Expelling the air and reattaching the
1. Manually deflate the balloon to assure all syringe helps to prevent accidental rein-
air is removed. flation of the balloon.
2. Tape the syringe used for inflation to the 5. The balloon should be left deflated to
head of the patient's allow for circulation distal to the balloon.
bed.
3. Leave the balloon inflated.
4. Expel all air from the syringe and reattach
to the catheter.
5. Leave the balloon deflated.
5. The nurse is preparing a client for insertion 2. "You will not feel the catheter as it is
of a pulmonary artery (PA) catheter. Which inserted."
information should the nurse provide?
2. The client will not feel the PA catheter
