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. Homocysteine is a marker for cardiovascular risk but is not used to monitor heart failure therapy.

B. LDL levels are associated with cholesterol management and do not directly reflect heart failure treatment effectiveness.

C. Troponin is a marker of myocardial injury, not heart failure severity.

D. B-type natriuretic peptide (BNP) levels correlate with the severity of heart failure and are used to monitor the effectiveness of heart failure therapy.

A. Obtain a stat chest x-ray to verify proper catheter placement. B. Zero reference and level the catheter at the phlebostatic-axis. C. Increase supplemental oxygen and notify respiratory therapy. D. Notify the provider immediately of the assessment findings.

Correct Answer is B

Explanation

A. Obtaining a stat chest x-ray is important if catheter misplacement is suspected, but in this situation, ensuring the accuracy of the pressure reading through proper leveling and zeroing is the priority.
B. Zero referencing and leveling the catheter at the phlebostatic axis is essential to ensure accurate readings of the pulmonary artery pressure, which is critical for patient assessment and management.
C. Increasing supplemental oxygen is unnecessary given the patient’s stable oxygen saturation and normal respiratory status.
D. While notifying the provider is important, ensuring the accuracy of the pressure reading by leveling and zeroing the catheter should be done first.

View Question and Answer

A nurse is caring for a client in the emergency department (ED).

<div id="exhibits">Exhibits</div>

The nurse is planning care for the client. For each potential prescription, indicate whether it is an anticipated (high priority), nonessential (low priority), contraindicated(unrelated).

Select one or more in each option.

View Question and Answer

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is B

Explanation

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