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?

Hypotension

Hypovolemia

Cardiogenic shock

Left ventricular failure

Answer and Explanation

The Correct Answer is D

Rationale:

A. Hypotension: Hypotension is typically associated with decreased preload and low PAWP rather than elevated values. An elevated PAWP reflects increased pressure in the left heart, which does not occur with simple hypotension alone.

B. Hypovolemia: Hypovolemia leads to decreased circulating blood volume, reducing preload and PAWP. It is typically marked by low filling pressures, not elevated wedge pressures.

C. Cardiogenic shock: Although cardiogenic shock can be associated with elevated PAWP due to poor cardiac output and fluid backup, it is not as specific a marker as left ventricular failure, which directly affects PAWP.

D. Left ventricular failure: Elevated PAWP reflects increased pressure in the left atrium and pulmonary circulation, which is a hallmark of left-sided heart failure. This elevation occurs because the failing left ventricle cannot efficiently pump blood forward.

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Correct Answer is B

Explanation

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.

A. Establish a patent oral airway. B. Remove the client's clothing. C. Warm blood products prior to administration. D. Assign the client a score on the Glasgow Coma Scale

Correct Answer is A

Explanation

Rationale:

A. Establish a patent oral airway: The airway is the highest priority in trauma care, following the ABCs (Airway, Breathing, Circulation). Without a patent airway, the client cannot oxygenate properly, which can quickly become life-threatening.

B. Remove the client's clothing: This helps with full-body assessment and prevention of missed injuries, but it should only be done after ensuring the client’s airway and breathing are stable.

C. Warm blood products prior to administration: While this helps prevent hypothermia during transfusion, warming blood is not the immediate priority in a trauma situation. Circulation support follows airway and breathing in priority.

D. Assign the client a score on the Glasgow Coma Scale: Neurological assessment is important but comes after airway stabilization. The GCS helps evaluate consciousness but should not delay securing the airway in an emergency.

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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?

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Naxlex Comprehensive Predictor Exams

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