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.
C
Balloon inflation should never be forced because the PAC may have migrated further 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.
You might also like to view...
A 5-year-old with a history of hypopituitarism comes to the physician with complaints of right hip and leg pain. The nurse understands that this symptom might be related to:
1. Daily growth hormone. 2. DDAVP (desmopressin acetate) at HS. 3. Insulin before meals and bedtime. 4. Cortisone injections.
The nurse is completing an admission assessment for a female adult client
When discussing the social history, the nurse identifies that the client is a smoker (one pack/day for 20 years) and has worked at a chemical plant operating a chemical packing machine. When reviewing this assessment, the nurse would consider this client at risk for A) environmental and occupational hazards that may affect life expectancy. B) increased life expectancy because she is female. C) no difference in risk because of her social and occupational circumstances. D) decreased fertility.
When teaching foot care to a client with chronic arterial occlusive disease, the nurse would tell the client to avoid
a. using cornstarch on the feet. b. using toenail clippers. c. wearing canvas shoes. d. wearing cotton socks.
A nurse identifies a nursing diagnosis of impaired urinary elimination related to urinary tract infection. When developing the plan of care, which of the following would be most important for the nurse to do first?
A) Develop a schedule for bladder emptying B) Encourage fluid intake C) Assess usual voiding patterns D) Monitor intake and output