The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care?
Provide passive range of motion for all extremities.
Position the patient supine with head flat at all times.
Measure the patient's urinary output every hour.
Avoid the use of anticoagulant medications.
The Correct Answer is C
A. Passive range of motion may be performed, but it is not the priority in this situation.
B. The head of the bed should be elevated 30 degrees or less, not necessarily flat, to prevent complications.
C. Hourly urinary output measurement is essential because the intra-aortic balloon pump (IABP) can impair renal perfusion, and monitoring urine output helps assess renal function.
D. Anticoagulants are often necessary to prevent clot formation associated with the IABP, so avoiding them is not advised unless contraindicated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. An electrophysiology study assesses the electrical activity of the heart but does not evaluate heart function or chamber size.
B. A 12-lead electrocardiogram records the electrical activity of the heart but does not provide detailed information on heart function or chamber size.
C. Cardiac catheterization is an invasive procedure used to assess coronary artery disease and other structural heart conditions but is not the primary study for evaluating heart function and chamber size.
D. An echocardiogram is a non-invasive ultrasound that provides detailed images of the heart, including its function, chamber size, and valve function, making it the best choice for this purpose.
Correct Answer is B
Explanation
A. There is no time to wait for a DNR order in an emergency; immediate action is needed.
B. Without a written DNR order, the nurse is legally and ethically obligated to initiate CPR and call the emergency response team to attempt to save the client’s life.
C. Contacting the risk manager is not an immediate action that would benefit the patient in this emergency situation.
D. The family’s wishes cannot be respected in this scenario without a formal DNR order in place; thus, the nurse must perform CPR.
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