While caring for a patient with a pulmonary arterial catheter, the nurse notes that the number of centimeters of exposed catheter has decreased. What nursing action is indicated?
1. Report this finding immediately; the patient may need another chest X-ray to check for placement.
2. Flush the ports.
3. Obtain a pulmonary artery occlusion pressure.
4. Zero balance the system.
1
Rationale 1: The distance the catheter is inserted should be documented and serves as a reference to other care providers. If the length changes, the change should be reported immediately because it could mean that the catheter has advanced and could puncture a structure within the vasculature.
Rationale 2: If the catheter is not in correct position, flushing the ports is contraindicated.
Rationale 3: If the catheter is not in the correct position, readings are inaccurate. This is not the priority intervention.
Rationale 4: There is no reason to zero balance the system at this time.
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a. Trust b. Preoperations c. Secondary circular reaction d. Sensorimotor period
Lymphoid tissue normally regresses to adult size by:
a. 2 years of age. b. 5 years of age. c. 10 years of age. d. puberty.
When assessing members of a vulnerable population, the community health nurse should realize that the primary need is to:
1. Provide culturally competent assessment. 2. Organize in your mind exactly what you need to ask. 3. Create a comfortable, nonthreatening environment. 4. Be alert for indications of mental and physical abuse.