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.

Answer and Explanation

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.

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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.

A. Take the family members quickly out of the patient room and remain with them. B. Tell the family members that watching the resuscitation will be very stressful. C. Ask family members if they wish to remain in the room during the resuscitation. D. Assign a staff member to wait with family members just outside the patient room.

Correct Answer is C

Explanation

A. Quickly removing the family members may add to their distress and does not respect their right to decide.

B. Telling them it will be stressful assumes their reaction without giving them a choice.

C. Allowing the family members to choose whether to stay respects their autonomy and can provide comfort during a difficult time. It is also in line with current best practices for family presence during resuscitation.

D. Assigning a staff member to wait outside is appropriate but should be done after offering the family the option to stay in the room.

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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?

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