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?

Cardiogenic shock

Left ventricular failure

Hypotension

Hypovolemia

Answer and Explanation

The Correct Answer is B

Choice A reason: Cardiogenic shock involves reduced cardiac output, typically with low PAWP due to decreased preload from poor heart function. Elevated PAWP reflects left atrial pressure buildup, not characteristic of cardiogenic shock alone, which is distinct from heart failure, requiring specific hemodynamic management.
Choice B reason: Elevated PAWP indicates left ventricular failure, where the heart cannot pump blood effectively, causing pulmonary congestion. This increases left atrial pressure, leading to pulmonary edema, a hallmark of heart failure. Diuretics and inotropes are needed to reduce fluid overload and improve cardiac function.
Choice C reason: Hypotension is a symptom, not a direct complication of elevated PAWP. It may occur in heart failure due to reduced cardiac output, but elevated PAWP specifically signals left heart dysfunction, not hypotension itself, which is a systemic response rather than a primary cardiac issue.
Choice D reason: Hypovolemia reduces blood volume, lowering PAWP due to decreased preload. Elevated PAWP suggests fluid overload or left ventricular dysfunction, not hypovolemia, which presents with low central venous pressure and dehydration signs, requiring fluid resuscitation rather than management of heart failure.

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Correct Answer is B

Explanation

Choice A reason: Hypernatremia is unlikely with 0.45% sodium chloride, a hypotonic solution that dilutes serum sodium. Over-infusion risks hyponatremia, not high sodium levels. Monitoring for hypernatremia is inappropriate, as the solution’s low sodium content does not contribute to elevated sodium in fluid therapy.
Choice B reason: Assessing for fluid overload is essential, as 0.45% sodium chloride, being hypotonic, can cause water to shift into cells, risking pulmonary or cerebral edema. This is critical in clients with renal or cardiac issues, where monitoring for dyspnea or swelling ensures safe fluid administration.
Choice C reason: Hypoglycemia is not directly linked to 0.45% sodium chloride, which affects fluid and electrolytes, not glucose. Fluid shifts may indirectly stress metabolism, but hypoglycemia relates to fasting or insulin issues, making this an inappropriate focus for monitoring in this fluid therapy context.
Choice D reason: Dehydration is unlikely, as 0.45% sodium chloride provides free water, promoting hydration. It corrects hypernatremia or replaces fluid losses. Evaluating for dehydration is unnecessary unless infusion is inadequate or losses persist, which is not indicated in the context of this hypotonic solution.

A. Administer calcium gluconate IV. B. Position the client supine. C. Prepare an IV bolus of dextrose. D. Administer methylergonovine IM.

Correct Answer is A

Explanation

Choice A reason: Calcium gluconate IV reverses magnesium sulfate toxicity, which causes respiratory depression or arrhythmias due to excessive magnesium. Calcium restores neuromuscular and cardiac function by competing with magnesium, preventing life-threatening complications like respiratory arrest in preeclampsia management.
Choice B reason: Positioning supine is inappropriate, as it does not address magnesium toxicity and may worsen respiration in preeclampsia. Semi-Fowler’s position optimizes breathing, while toxicity requires pharmacological reversal with calcium gluconate, not positional changes, to manage life-threatening symptoms effectively.
Choice C reason: IV dextrose is irrelevant for magnesium toxicity, which affects neuromuscular function, not glucose levels. Dextrose treats hypoglycemia, not applicable here. Magnesium overdose requires calcium to counteract effects, making dextrose an ineffective intervention in preeclampsia-related toxicity management.
Choice D reason: Methylergonovine, a uterotonic, is contraindicated in preeclampsia, as it increases blood pressure, risking hypertensive crisis. It treats postpartum hemorrhage, not magnesium toxicity, which requires calcium gluconate to reverse neuromuscular depression, ensuring safety in preeclampsia management.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving 0.45% sodium chloride. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displays toxicity. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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