Which findings would suggest to the nurse that the balloon of a pulmonary artery catheter (PAC) has ruptured? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. No pulmonary artery occlusion pressure tracing appears when the balloon is inflated.
2. Blood is noted in the air inflation port.
3. It is not possible to pull air back out of the balloon with the syringe.
4. A right bundle branch block appears on the electrocardiogram tracing.
5. The normal pulmonary artery waveform does not return after obtaining the pulmonary artery occlusion pressure.
1,2
Rationale 1: If the balloon has ruptured, it will not occlude the artery and no tracing will appear.
Rationale 2: Blood in the inflation port indicates that the balloon has allowed leakage back into the catheter. This would occur if the balloon was not intact.
Rationale 3: The balloon should be allowed to deflate passively. Using the syringe to remove air may cause balloon rupture.
Rationale 4: This conduction defect is more likely to occur if the catheter tip has advanced through the right ventricle.
Rationale 5: If the normal pulmonary artery waveform does not return, it is more likely that the balloon is wedged despite deflation.
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