A nurse is monitoring the cardiac output of a client who has left-sided heart failure using pulse pressure analysis. Which of the following findings can compromise the readings?
The client is experiencing premature atrial contractions.
The client has bilateral wheezes.
The client has a decreased oxygen saturation level.
The client has lower leg edema.
The Correct Answer is A
A. The client is experiencing premature atrial contractions is correct. Premature atrial contractions can interfere with pulse pressure analysis and affect the accuracy of cardiac output measurements.
B. The client has bilateral wheezes is incorrect. Wheezes affect lung function, not directly the accuracy of pulse pressure analysis for cardiac output.
C. The client has a decreased oxygen saturation level is incorrect. While it is a concern, it does not compromise pulse pressure readings directly.
D. The client has lower leg edema is incorrect. Edema affects peripheral circulation but does not directly compromise pulse pressure measurements for cardiac output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
- Incisional Site Bleeding: This is important to check as it indicates possible complications like infection or hematoma formation at the pacemaker insertion site.
- Bradycardia: It is essential to ensure that the pacemaker is functioning correctly and managing bradycardia as intended. Continuous monitoring is needed to detect any issues related to pacemaker settings or lead placements.
Correct Answer is []
Explanation
Condition:
A. Transfusion-associated circulatory overload (TACO)
Rationale: The client’s symptoms—dyspnea, restlessness, crackles in the lungs, jugular vein distension, and elevated blood pressure—are consistent with TACO, a condition resulting from excessive fluid volume during a blood transfusion.
Actions to Take:
C. Administer furosemide
Rationale: Furosemide is a diuretic that helps reduce fluid overload, which is a key issue in TACO.
B. Administer diphenhydramine
Rationale: Although not the primary treatment for TACO, diphenhydramine can help manage symptoms if there is a mild allergic reaction contributing to the situation.
Parameters to Monitor:
A. Intake and output
Rationale: Monitoring intake and output helps assess fluid balance and effectiveness of treatment for TACO.
D. Weight
Rationale: Weight monitoring helps assess fluid overload and effectiveness of diuretic therapy
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