A client has hemodynamic monitoring after a myocardial ...

[s.tung]

A client has hemodynamic monitoring after a myocardial infarction. What safety precaution does the nurse implement for this client?
 
  a. Document pulmonary artery wedge pressure (PAWP) readings and assess their trends.
  b. Ensure the balloon does not remain wedged.
  c. Keep the client on strict NPO status.
  d. Maintain the client in a semi-Fowler's position.

Question 2

The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.)
 
  a. Administer antibiotics.
  b. Draw serum lactate levels.
  c. Infuse vasopressors.
  d. Measure central venous pressure.
  e. Obtain blood cultures.

[Qarqy]

Answer to Question 1

ANS: B
If the balloon remains inflated, it can cause pulmonary infarction or rupture. The nurse should ensure the balloon remains deflated between PAWP readings. Documenting PAWP readings and assessing trends is an important nursing action related to hemodynamic monitoring, but is not specifically related to safety. The client does not have to be NPO while undergoing hemodynamic monitoring. Positioning may or may not affect readings.

Answer to Question 2

ANS: A, B, E
Within the first 3 hours of suspecting severe sepsis, the nurse should draw (or facilitate) serum lactate levels, obtain blood cultures (or other cultures), and administer antibiotics (after the cultures have been obtained). Infusing vasopressors and measuring central venous pressure are actions that should occur within the first 6 hours.