The nurse is preparing for insertion of a pulmonary artery catheter (PAC). During insertion of the catheter, what are the priority nursing actions? (Select all that apply.)
a. Allay the patient's anxiety by providing information about the procedure.
b. Ensure that a sterile field is maintained during the insertion procedure.
c. Inflate the balloon during the procedure when indicated by the physician.
d. Monitor the patient's cardiac rhythm throughout the entire procedure.
e. Obtain informed consent by informing the patient of procedural risks.
A, B, C, D
During insertion of a pulmonary artery catheter (PAC/Swan-Ganz), the nurse should allay the patient's anxiety, ensure that the sterile field is maintained to decrease the risk of infection, inflate the balloon upon request of the physician to assist in catheter placement, and monitor for dysrhythmias that may occur as the catheter passes through the right ventricle. Informed consent may be witnessed by the nurse, but it is obtained by the physician and should occur before the procedure begins.
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