Question

The client is admitted to the intensive care area following a coronary artery bypass graft. The nurse caring for the client manages the fluid volume status by checking the central venous pressure and finds a reading of \(4 \mathrm{~mm} \mathrm{Hg}\). Which action should the nurse take at this time? A. Increase the rate of IV fluid using the protocol provided B. Continue her care with no further action C. Decrease the IV fluid using the protocol provided D. Administer furosemide (Lasix) as ordered

Short answer

Answer: B. Continue her care with no further action.

Step-by-step solution

Understand the normal range of central venous pressure

The normal range of central venous pressure (CVP) is around 2 to 8 mm Hg. A CVP of 4 mm Hg is within the normal range which indicates that fluid volume status is adequate.

Evaluate the options provided

A. Increase the rate of IV fluid using the protocol provided - This option is not recommended as the CVP is within the normal range, meaning that the fluid volume status is adequate. B. Continue her care with no further action - This option might be appropriate since the CVP is within the normal range. The nurse may continue monitoring the patient's condition without making changes in fluid management. C. Decrease the IV fluid using the protocol provided - This option is also not recommended because the CVP is within the normal range, indicating that fluid volume status is adequate. D. Administer furosemide (Lasix) as ordered - This is a diuretic and would be used for high CVP. Considering that the CVP of 4mm Hg is not elevated, this option is not appropriate.

Choose the correct answer

Based on the analysis of the options and understanding of the normal range of central venous pressure, the correct answer is: B. Continue her care with no further action