Author Question: A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes ... (Read 109 times)

DelorasTo · **on:** Jun 25, 2018

A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the client's heart rate has increased from 88 to 110 beats/min, and the blood pressure dropped from 120/82 to 100/60 mm Hg.

What action by the nurse is most appropriate?

a.
Allow the client to rest quietly.
b.
Assess the client for bleeding.
c.
Document the findings in the chart.
d.
Medicate the client for pain.

Question 2

A client undergoing hemodynamic monitoring after a myocardial infarction has a right atrial pressure of 0.5 mm Hg. What action by the nurse is most appropriate?

a. Level the transducer at the phlebostatic axis.
b. Lay the client in the supine position.
c. Prepare to administer diuretics.
d. Prepare to administer a fluid bolus.

taylorsonier · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: B
A major complication related to intra-arterial blood pressure monitoring is hemorrhage from the insertion site. Since these vital signs are out of the normal range, are a change, and are consistent with blood loss, the nurse should assess the client for any bleeding associated with the arterial line. The nurse should document the findings after a full assessment. The client may or may not need pain medication and rest; the nurse first needs to rule out any emergent bleeding.

Answer to Question 2

ANS: D
Normal right atrial pressures are from 1 to 8 mm Hg. Lower pressures usually indicate hypovolemia, so the nurse should prepare to administer a fluid bolus. The transducer should remain leveled at the phlebostatic axis. Positioning may or may not influence readings. Diuretics would be contraindicated.