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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Securing the drain to the client's bed sheet is not an appropriate method for securing the JP drain; it should be secured to the client’s gown or clothing to avoid tension on the drain.

B. Expelling the air from the JP bulb after emptying to re-establish suction is necessary to ensure that the drain continues to function correctly by maintaining negative pressure.

C. Measuring the drainage every hour for the first 8 hr postoperative is more frequent than necessary; monitoring can be done every 4-8 hours depending on the protocol.

D. Removing the JP drain when the drainage has ceased, covering the opening with sterile gauze is incorrect; the drain should be removed per the surgeon’s orders, and the site should be covered with a sterile dressing.

A. Keep the leg in a dependent position. B. Apply ice to the affected area. C. Begin active range of motion. D. Remain on bedrest for the first 24 hr.

Correct Answer is B

Explanation

A. Keeping the leg in a dependent position can increase swelling; the leg should be elevated to reduce swelling.
B. Applying ice to the affected area is recommended to reduce swelling and pain after arthroscopic knee surgery.
C. Active range of motion exercises might be recommended, but this depends on the surgeon’s instructions and typically starts after the initial recovery period.
D. Bedrest for 24 hours is not usually required; gentle movement and following specific rehabilitation protocols are encouraged.

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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?

Nursing Test Bank

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