Difficulty: Medium
Average Score: 63%
Practice
When performing an initial pulmonary artery occlusion pr essure (PAOP), what are the best nursing actions? (Select all that apply.)
Correct answer
A
Rationale
The correct answer is A: Inflate the balloon for no more than 8 to 10 seconds while noting the waveform change. This is because inflating the balloon within this time frame allows for accurate measurement of PAOP without causing complications like pulmonary edema. Noting the waveform change helps in determining the accurate pressure reading.
Explanation of why other choices are incorrect:
B: Inflating the balloon with air and recording the volume necessary is not a recommended practice as it can lead to inaccurate readings and potential harm to the patient.
C: Maintaining the balloon inflated for 8 hours following insertion is unnecessary and could lead to complications such as vascular damage or thrombosis.
D: Zero referencing and leveling the transducer at the phlebostatic axis are important steps but not directly related to performing an initial PAOP measurement.
Explanation of why other choices are incorrect:
B: Inflating the balloon with air and recording the volume necessary is not a recommended practice as it can lead to inaccurate readings and potential harm to the patient.
C: Maintaining the balloon inflated for 8 hours following insertion is unnecessary and could lead to complications such as vascular damage or thrombosis.
D: Zero referencing and leveling the transducer at the phlebostatic axis are important steps but not directly related to performing an initial PAOP measurement.