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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Use a powered lift to transfer the client: When a client is unable to assist and weighs significantly over standard lifting limits, a powered mechanical lift is the safest and most appropriate method. It reduces the risk of musculoskeletal injury to staff and ensures safe, controlled client movement.
B. Wrap their arms under the client's axilla to transfer the client: This manual lifting method can cause harm to both the nurse and the client. It increases the risk of shoulder injury for the client and back strain for the nurse, especially when the client is immobile and heavy.
C. Use a gait belt to transfer the client: Gait belts are used for clients who can bear some weight and assist in the transfer. Since this client cannot assist, a gait belt is insufficient and may result in injury or unsafe movement.
D. Use a sliding board to transfer the client: Sliding boards are typically used when clients have upper body strength and can assist in shifting their weight. For a fully dependent client of this size, it is not a safe or effective method without mechanical assistance.
Correct Answer is B
Explanation
Rationale:
A. Tenting skin turgor: Tenting indicates dehydration or fluid volume deficit, not overload. It reflects reduced skin elasticity due to poor interstitial fluid volume.
B. Respiratory rate 30/min: Tachypnea can result from pulmonary congestion or edema due to excess fluid in the intravascular space. It is a classic sign of fluid overload as the lungs struggle with impaired gas exchange.
C. Skin warm and dry: Warm, dry skin is a normal finding and does not suggest volume overload. Fluid retention typically causes edema or moist skin in severe cases.
D. Heart rate 60/min: A heart rate within normal range does not point to fluid overload. Often, fluid overload is associated with tachycardia due to increased preload and compensatory responses.
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