Difficulty: Medium
Average Score: 93%
Practice
The nurse is caring for a mechanically ventilated patient b eing monitored with a left radial arterial line. During the inspiratory phase of ventilation, th e nurse assesses a 20 mm Hg decrease in arterial blood pressure. What is the best interpretation of this finding by the nurse?
Correct answer
B
Rationale
The correct answer is B: The patient may require fluid resuscitation. A decrease in arterial blood pressure during the inspiratory phase of ventilation suggests decreased preload, indicating possible hypovolemia. This can be addressed by administering fluid resuscitation to improve cardiac output and blood pressure.
Incorrect Choices:
A: The mechanical ventilator is malfunctioning - There is no evidence to suggest a ventilator malfunction based on the arterial pressure change.
C: The arterial line may need to be replaced - The arterial line itself is unlikely to cause the observed pressure change.
D: The left limb may have reduced perfusion - This is less likely as the pressure change is likely systemic due to decreased preload.
Incorrect Choices:
A: The mechanical ventilator is malfunctioning - There is no evidence to suggest a ventilator malfunction based on the arterial pressure change.
C: The arterial line may need to be replaced - The arterial line itself is unlikely to cause the observed pressure change.
D: The left limb may have reduced perfusion - This is less likely as the pressure change is likely systemic due to decreased preload.