(Osborn) Chapter 24: Learning Outcomes (Number and Title)

[Osborn] chapter 24
Learning Outcomes [Number and Title ]

Learning Outcome 1
Explain the concept of hemodynamic monitoring.
Learning Outcome 2
Identify components of a hemodynamic monitoring system.
Learning Outcome 3
Compare and contrast arterial, central venous, and pulmonary
artery pressure monitoring.
Learning Outcome 4
Identify adequate central venous and pulmonary artery
pressures.
Learning Outcome 5
Evaluate nursing management of arterial lines and central
venous and pulmonary artery catheters.
Learning Outcome 6
Discuss how alterations in preload, afterload, and contractility
affect cardiac output.
Learning Outcome 7
Compare and contrast how measurements obtained from a
central venous catheter differ from the data obtained from a
pulmonary artery catheter.
Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.
1. The nurse is orienting to care for patients in the intensive care area. Which of the
following statements indicates that the new nurse needs more information about
hemodynamic monitoring?
1. One drawback of hemodynamic monitoring is that the catheter must go
through the heart and into the pulmonary artery.
2. Hemodynamic monitoring data can be used to aid in the diagnosis of lung
disorders.
3. Hemodynamic monitoring data can help to guide fluid administration and
prevent fluid overload.
4. Data from hemodynamic monitoring can be used to evaluate the patients
progress.
Correct Answer: One drawback of hemodynamic monitoring is that the catheter must go
through the heart and into the pulmonary artery.
Rationale: The pulmonary artery catheter does go through the heart and into the
pulmonary artery; however, hemodynamic monitoring can also be accomplished through
a peripheral arterial line. The other answer choices are true and indicate that the nurse has
a good understanding of hemodynamic monitoring.
Cognitive Level: Evaluating
Nursing Process: Evaluation
Client Need: Safe, Effective Care Environment
LO: 1

Inc.
2. A family member of a critically ill patient is verbalizing the purpose of hemodynamic

monitoring. Which of the following statements indicates that the family member needs
more education?
1. The hemodynamic monitor can measure how much blood is in the arteries
and veins.
2. The hemodynamic monitor can measure how much oxygen is left in the
blood after it circulates through the body.
3. The hemodynamic monitor can measure how much pressure is in the heart.
4. The hemodynamic monitor can measure how much blood comes out of the
heart each minute.
Correct Answer: The hemodynamic monitor can measure how much blood is in the
arteries and veins.
Rationale: The family member of the critically ill patient would need further teaching if
he or she thought the hemodynamic monitor could measure the volume of blood in the
vascular system. The pressure monitoring can see trends in pressure, which may
indirectly be related to volume or to decreased vascular resistance. The nurse and
physician would need to interpret this data to determine the cause of the change. The
other answer choices are true and indicate that the family member has a good
understanding of hemodynamic monitoring.
Client Need: Health Promotion and Maintenance
LO: 1

Inc.
3. A patient is concerned about the arterial line waveform pattern because there is a break
in the downward slope of the pattern and something must be wrong since it is not a
smooth line. Which of the following is the nurses best response to this patient?
1. What you are seeing is called a dicrotic notch, and it means the beginning of the
resting phase of your heart.
2. You are right. I will see if you are prescribed any medication for that problem.
3. It is nothing for you to be concerned about. It is just a measurement of your
blood pressure.
4. You are seeing the strongest part of your heart muscle, which is the first number
of a blood pressure reading.
Correct Answer: What you are seeing is called a dicrotic notch, and it means the
beginning of the resting phase of your heart.
Rationale: The dicrotic notch represents closure of the aortic valve and distinguishes the
beginning of diastole or the resting phase of the heart ventricles. The nurse should explain
the notch to the patient and that it means the beginning of the hearts resting phase. The
nurse should not agree with the patient by saying that there is something wrong and that
the patient might need medication. The nurse should not minimize the patients concern.
The dicrotic notch does not signify systole or the first number of a blood pressure
reading.
Cognitive Level: Applying
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 1

Inc.
4. An important role of the nurse who is caring for a patient with an invasive
hemodynamic monitoring includes:
1. Frequent reassessment and evaluation of data in order to tailor therapies to the
patient.
2. Keeping IV solutions at atmospheric pressure so the monitor accurately
obtains patient pressures.
3. Using the hemodynamic line for monitoring pressures and not for infusing IV
fluids.
4. Zero referencing the transducer to the level of the radial artery.
Correct Answer: Frequent reassessment and evaluation of data in order to tailor therapies
to the patient.
Rationale: An important role of the nurse caring for a patient with an invasive
hemodynamic monitoring includes frequent reassessment and evaluation of data in order
to tailor therapies to the patient. Fluids and medications are often changed when the nurse
reports changes in hemodynamic data to the health care provider. IV solutions are kept at
300 mmHg. Fluids are infused constantly through the system to prevent clotting of the
line. The hemodynamic transducer is zeroed using the phlebostatic axis as a reference.
Cognitive Level: Analyzing
LO: 2

Inc.
5. The nurse is setting up hemodynamic monitoring. The purpose of the dynamic wave
test, also known as the square wave test, is to determine whether the:
1. Transducer is accurately reflecting pressure in the vessel.
2. Line is at the correct level to measure hemodynamic pressures.
3. Radial artery can be used for monitoring.
4. Hemodynamic line has the correct amount of pressure in it.
Correct Answer: Transducer is accurately reflecting pressure in the vessel.
Rationale: The purpose of the dynamic wave test, also known as the square wave test, is
to determine whether the transducer is accurately reflecting pressure in the vessel. The
phlebostatic access is used to determine the correct level to measure hemodynamic
pressures. The Allens test is used to measure whether the radial artery can be used for
monitoring. The pressure should remain relatively constant at 300 mmHg for accurate
hemodynamic monitoring.
Nursing Process: Assessment
LO: 2

Inc.
6. A patient with an arterial line has just been turned and repositioned. After leveling the
transducer, which of the following should the nurse do next?
1.
2.
3.
4.
Zero the transducer.

Fast flush the catheter.
Increase the arterial line infusion to 5 ml/hour.
Turn the stopcock closest to the patient to the on position.
Correct Answer: Zero the transducer.

Rationale: Zeroing the transducer should be done after turning the patient, once the
transducer has been leveled. Fast flushing the catheter is done to test whether the
transducer is accurately transmitting the pressure detected in the vessel. The arterial line
infusion should be set at 1 to 3 ml/hour. Turning the stopcock closest to the patient to the
on position is done after the transducer has been zeroed.
LO: 2

Inc.
7. When comparing arterial, central venous, and pulmonary arterial pressures, the nurse
knows that:
1. The normal pressure in the right atrium of the heart is very low, 2 to 6 mm/Hg.
2. The small vessels of the pulmonary arteries are under more pressure than
systemic arterial blood pressure.
3. It is not a good idea to measure the patients blood pressure from the arterial
waveform tracing.
4. The pressures in the superior and inferior vena cava are lower than the
pressure in the right atrium of the heart.
Correct Answer: The normal pressure in the right atrium of the heart is very low, 2 to 6
mm/Hg.
Rationale: The normal pressure in the right atrium of the heart is very low, 2 to 6 mm/Hg,
and is equal to the pressures in the superior and inferior vena cava because there is no
valve between the vena cava and the right atrium. Pulmonary arterial pressure is normally
lower than systemic arterial blood pressure. The arterial waveform tracing is an accurate
way to measure blood pressure as long as the blood pressure was measured accurately.
LO: 3

Inc.
8. A critically ill patient is admitted for the treatment of sepsis. The right arterial BP is
90/60, the central venous pressure is 2, and the pulmonary arterial pressure is 20/8. What
assessment can the nurse make from this data?
1. The patient may require additional fluids because all pressures are low.
2. The patient is stable and should continue to be monitored hourly due to the
presence of sepsis.
3. The pressure in the lungs is high even though the other pressures are low. The
doctor should be notified and STAT X-ray expected.
4. The pressure in the right atrium is 2, which is inaccurate. The line should be
flushed and re-zeroed before an evaluation can be made.
Correct Answer: The patient may require additional fluids because all pressures are low.
Rationale: The arterial, central venous, and pulmonary arterial pressures are all low.
Sepsis is a type of distributive shock. The nurse would expect to give a fluid bolus in this
situation as well as initiate or continue other therapies for sepsis.
LO: 3

Inc.
9. The nurse reviewing the waveform of a patients central venous pressure line notes two
positive waves. Which of the following does this information suggest to the nurse?
1.
2.
3.
4.
The c wave is not always visible on the tracing.

The line is no longer in the correct position.
The wave is not visible during systole.
The wave is not visible during diastole.
Correct Answer: The c wave is not always visible on the tracing.

Rationale: The normal central venous pressure waveform has three positive waves. The a
wave correlates with systole. The c wave reflects retrograde swelling of the tricuspid
valve into the right atrium and may not be visible on the tracing. The v wave represents
diastole. With the presence of the other waves, the catheter is in the correct position in the
patient.
LO: 3

Inc.
10. The nurse is monitoring central venous pressure. Which statement is correct regarding
central venous monitoring?
1. An increasing trend in central venous pressure may result from fluid building
in the lungs.
2. A decreasing trend in central venous pressure may indicate right heart failure.
3. It is better to look at current numbers for central venous pressure monitoring
rather than trends.
4. Central venous pressure is a direct measurement of systemic vascular
resistance.
Correct Answer: An increasing trend in central venous pressure may result from fluid
building in the lungs.
Rationale: An increasing trend in central venous pressure may result from fluid building
in the lungs. As pressure in the lungs increases, volume in the right heart will increase,
which will increase the CVP. Right heart failure would also cause an increasing CVP. It is
more accurate to look at trends rather than one CVP reading. CVP is not a direct
measurement of systemic vascular resistance.
LO: 4

Inc.
11. A nurse is preparing to inflate the balloon located in the pulmonary artery. What is the
purpose of inflating the balloon?
1. When inflated, the catheter indirectly measures pressures in the left side of the
heart.
2. When inflated, the catheter measures cardiac output through thermodilution.
3. When inflated, the catheter measures the pressure in the right side of the heart.
4. When inflated, the catheter indirectly measures the cardiac index.
Correct Answer: When inflated, the catheter indirectly measures pressures in the left side
of the heart.
Rationale: Inflating the balloon in the pulmonary artery catheter indirectly measures
pressures in the left side of the heart. Cardiac output is measured though a thermistor
located within the catheter. The cardiac index is a calculation of the cardiac output
divided by the body surface area.
Nursing Process: Planning
LO: 4

Inc.
12. A patients central venous pressure reading is 8 mm Hg. The nurse realizes this
reading reflects which of the following?
1.
2.
3.
4.
The blood pressure within the right atrium

The blood pressure within the left atrium
The blood pressure within the pulmonary artery
The blood pressure within the left ventricle
Correct Answer: The blood pressure within the right atrium

Rationale: The central venous pressure reflects the blood pressure of the vena cava and
the right atrium. The other choices do not reflect the central venous pressure.
LO: 4

Inc.
13. While caring for a patient with a pulmonary artery catheter, which of the following is
not within the scope of practice of the nurse?
1. Advancing the catheter if the radiologist determines it is not in the pulmonary
artery
2. Inflating the balloon in the pulmonary artery to obtain pulmonary artery
occlusion pressures
3. Using sterile technique to clean the site of insertion of the catheter and
changing the dressing
4. Changing the dosages (titrating) of medications based on changes in
hemodynamic pressures
Correct Answer: Advancing the catheter if the radiologist determines it is not in the
pulmonary artery
Rationale: The nurse does not advance the catheter through the heart. The nurse does
inflate the balloon, use sterile technique to change the dressing and clean the site, and
change the dosages of medications (titrate) based on the patients response to therapy.
LO: 5

Inc.
14. While caring for a patient with a right radial arterial line, the nurse assesses that the
right fingers are cool, pale, and dusky. Which intervention would be important to do first?
1. Notify the physician STAT.
2. Flush the arterial catheter and zero the line.
3. Try to obtain a pulse using Doppler ultrasound.
4. Obtain a blood pressure in the left arm.
Correct Answer: Notify the health care provider STAT.
Rationale: The health care provider needs to be notified STAT and the line needs to be
discontinued. Symptoms including cool, pale, and dusky skin indicate arterial occlusion,
and this is a medical emergency. Loss of arterial circulation will cause loss of the limb
distal to the occlusion unless circulation can be restored. The remaining actions do not
take priority over notifying the health care provider.
LO: 5

Inc.
15. While caring for a patient with a pulmonary arterial catheter, the nurse notes that the
number of centimeters of the catheter has decreased. Which of the following should be
done at this time?
1. Report this finding immediately; the patient may need another chest x-ray to
check for placement.
2. Flush the ports.
3. Zero balance the system.
4. Obtain a pulmonary artery occlusion pressure.
Correct Answer: Report this finding immediately; the patient may need another chest xray to check for placement.
Rationale: 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. The other choices would be inappropriate for the nurse
to do at this time.
Nursing Process: Implementing
LO: 5

Inc.
16. The nurse is noticing an increasing afterload in a patient in the ICU. How does the
increasing afterload affect cardiac output?
1. If afterload is high, cardiac output will be deceased due to high systemic
vascular resistance.
2. If afterload is high, cardiac output will be increased due to the increased
volume in the heart.
3. If afterload is high, cardiac output will be deceased due to decreased
contractility.
4. If afterload is high, cardiac output will be increased because the heart rate
increases during afterload.
Correct Answer: If afterload is high, cardiac output will be deceased due to high systemic
vascular resistance.
Rationale: Afterload measures the pressure that is needed to eject blood out of the heart.
Systemic vascular resistance is the main factor that affects afterload. High resistance
impedes flow and decreases cardiac output. Contractility may increase with high
afterload to compensate for low stroke volume, or it may decrease if the patient
decompensates. Either way, decreased contractility does not cause high afterload.
LO: 6

Inc.
17. The nurse is attempting to increase contractility to improve cardiac output in a patient
with acute exacerbation of heart failure. Which of the following measures would be
helpful to improve cardiac contractility?
1. Correcting oxygenation and mild respiratory acidosis
2. Encouraging the patient to exercise
3. Administering magnesium sulfate
4. Giving the patient a beta-adrenergic blocking medication
Correct Answer: Correcting oxygenation and mild respiratory acidosis
Rationale: Achieving normal oxygenation and correcting acidosis will improve cardiac
contractility. Encouraging exercise in a patient with acute exacerbation of heart failure is
an unsafe intervention. Both magnesium (a smooth muscle relaxant) and beta-adrenergic
blocking medication would decrease cardiac contractility.
LO: 6

Inc.
18. The nurse is providing care for a patient diagnosed with an increase in afterload and a
CVP reading of 7 mm Hg. Which of the following will be included in this patients plan
of care?
1.
2.
3.
4.
Provide diuretic therapy as prescribed.

Provide plasma.
Provide intravenous fluids.
Encourage an increase in fluids by mouth.
Correct Answer: Provide diuretic therapy as prescribed.

Rationale: Excessive preload is evidenced by a CVP reading of greater than 6 mm Hg.
The patient has excessive circulation, which strains the heart, increases the workload of
the heart, and increases myocardial oxygen demands. Diuretic therapy would be indicated
for this patient. Plasma, intravenous fluids, and oral fluids would all be indicated for a
patient who is diagnosed with a decrease in preload and hypovolemia.
LO: 6

Inc.
19. When comparing pressures obtained from the central venous pressure (CVP) versus
pressures obtained from the pulmonary arterial pressure, the nurse knows that:
1. The CVP is expected to be a low pressure while the PAP is the highest
pressure obtained in the pulmonary artery catheter.
2. The CVP is expected to be the highest pressure obtained in the pulmonary
artery catheter while the PAP is expected to be a low pressure.
3. The CVP and the PAP pressures cannot be compared because these pressures
are based on individual patients and their conditions.
4. The individual pressures obtained in the CVP and the PAP are not relevant.
The pressure trends guide patient care.
Correct Answer: The CVP is expected to be a low pressure while the PAP is the highest
pressure obtained in the pulmonary artery catheter.
Rationale: The CVP is expected to be a low pressure while the PAP is the highest
pressure obtained in the pulmonary artery catheter. Normal CVP readings vary from 2 to
6 mmHg, and normal PAP pressures vary from 20 to 30 mmHg systolic, and 0 to 8
mmHg diastolic. While pressure readings do vary between individuals, there are expected
norms for the CVP and PAP. Individual pressures ARE relevant, but it is also true that
trends are used to guide patient care.
LO: 7

Inc.
20. A critically ill patient is admitted for the treatment of pneumonia and is receiving
mechanical ventilation. The central venous pressure (CVP) is 15, and the pulmonary
arterial pressure (PAP) is 55/35. What evaluation can the nurse make from this data?
1. Since both pressures are high, the patient has increased pressure in the lungs
and also has a high fluid volume.
2. Since the CVP is high, the patient has increased fluid volume, and the low
PAP indicates impending heart failure.
3. The CVP is low because the patient has increased fluid volume, and the high
PAP indicates increased pressure in the lungs.
4. Both pressures are low because the patient has increased fluid volume, and
may be septic from the pneumonia.
Correct Answer: Since both pressures are high, the patient has increased pressure in the
lungs and also has a high fluid volume.
Rationale: Both the CVP and the PAP are extremely high. The high PAP indicates
pressure in the lungs and is partially caused by mechanical ventilation as well as the
pneumonia. The high CVP indicates increased fluid volume. The nurse would evaluate
for signs of heart failure as well as signs of renal failure in this critically ill patient.
LO: 7

Inc.
21. The nurse observes that a patient being monitored with a pulmonary artery catheter
has a missing c wave. Which of the following does this finding suggest?
1.
2.
3.
4.
It is difficult to determine the pulmonary artery occlusion pressure.

Nothing, because this wave is often missing from view.
It should appear at the end of the QRS complex.
It should appear simultaneously with the T-P interval of the ECG.
Correct Answer: It is difficult to determine the pulmonary artery occlusion pressure.

Rationale: Identification of the c wave on a pulmonary artery catheter tracing is important
because prior to the c wave occurring, the pressure equilibrates between the atrium and
the ventricle. If the c wave is missing, the pulmonary artery occlusion pressure is
obtained by averaging the a wave and x wave. The c wave is often missing with a central
venous pressure monitor tracing. The a wave appears near the end of the QRS complex.
The v wave appears simultaneously with the T-P interval of the ECG.
LO: 7

Inc.

(Osborn) Chapter 24: Learning Outcomes (Number and Title)

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[Osborn] chapter 24

Learning Outcomes [Number and Title ]

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

2. A family member of a critically ill patient is verbalizing the purpose of hemodynamic

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Zero the transducer.

Correct Answer: Zero the transducer.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

The c wave is not always visible on the tracing.

Correct Answer: The c wave is not always visible on the tracing.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

The blood pressure within the right atrium

Correct Answer: The blood pressure within the right atrium

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Provide diuretic therapy as prescribed.

Correct Answer: Provide diuretic therapy as prescribed.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Osborn, et al., Test Item File for Medical-Surgical Nursing:

It is difficult to determine the pulmonary artery occlusion pressure.

Correct Answer: It is difficult to determine the pulmonary artery occlusion pressure.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

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