A nurse is assessing a client's pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications?

Rationale:

A. Measure the client's apical pulse while another nurse measures their radial pulse: Assessing for a pulse deficit involves comparing the apical and radial pulses simultaneously. A difference between the two indicates that not all heartbeats are reaching peripheral circulation, often seen in arrhythmias like atrial fibrillation.

B. After inflation, deflate a blood pressure cuff on the client's arm while palpating their brachial pulse: This method is used for measuring blood pressure, not for identifying pulse deficits. It does not provide information on the difference between central and peripheral pulse rates.

C. Compare the client's carotid pulse while resting to their carotid pulse after standing for 1 min: This assesses for orthostatic changes, not pulse deficit. Pulse deficit requires comparison of apical and radial pulses, not positional changes in carotid pulse strength or rate.

D. Assess both of the client's radial pulses at the same time and compare the quality of pulsations: Comparing bilateral radial pulses helps detect differences in circulation or vessel obstruction but does not assess for a pulse deficit, which specifically involves apical-radial pulse comparison.

Rationale:

A. The nurse positions a client who is postoperative in a semi-Fowler's position: Semi-Fowler's position is commonly used postoperatively to promote lung expansion, prevent aspiration, and support comfort. This is an appropriate nursing action that does not require correction.

B. The nurse performs auscultation of the lungs without lifting the gown: Lung auscultation should always be performed on bare skin to ensure accurate assessment of breath sounds. Clothing can muffle or distort the sounds, potentially leading to misinterpretation or missed abnormalities.

C. The nurse applies a cold compress to reduce localized swelling: Cold therapy is appropriate for managing inflammation, bruising, or swelling in many clinical settings. This demonstrates correct therapeutic intervention and does not indicate a need for further instruction.

D. The nurse uses clean gloves when administering an enema: Clean (non-sterile) gloves are appropriate for enema administration since it is a non-sterile procedure. This action follows standard precautions and is acceptable for routine nursing care.