A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions?

Hemodynamic status

Spinal cord perfusion

Renal function

Intracranial pressure

Answer and Explanation

The Correct Answer is A

Choice A Reason: This is correct because a pulmonary artery catheter is a device that measures the pressures and ﬂows in the heart and lungs, such as the pulmonary artery pressure, the pulmonary artery wedge pressure, the cardiac output, and the mixed venous oxygen saturation. These parameters reﬂect the hemodynamic status of the client, which is the balance between the cardiac output and the systemic vascular resistance.

Choice B Reason: This is incorrect because a pulmonary artery catheter does not measure spinal cord perfusion, which is the blood ﬂow to the spinal cord. Spinal cord perfusion can be aﬀected by spinal cord injury, spinal anesthesia, or spinal surgery.

Choice C Reason: This is incorrect because a pulmonary artery catheter does not measure renal function, which is the ability of the kidneys to filter waste products and maintain ﬂuid and electrolyte balance. Renal function can be assessed by urine output, blood urea nitrogen, creatinine, and glomerular filtration rate.

Choice D Reason: This is incorrect because a pulmonary artery catheter does not measure intracranial pressure, which is the pressure inside the skull. Intracranial pressure can be increased by brain injury, stroke, tumor, infection, or hydrocephalus.

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Correct Answer is B

Explanation

Choice A Reason: This is incorrect because the client is not unconscious, as the GCS score ranges from 3 to 15, with 3 being the lowest possible score and indicating deep coma or death.

Choice B Reason: This is correct because the client can follow simple motor commands, as the GCS score for best motor response is 5, which means the client can localize pain by moving his limbs away from the source of stimulation.To interpret the Glasgow Coma Scale (GCS) score provided in the scenario:Eye Opening (E): 3 - The client opens their eyes in response to verbal stimuli.Best Verbal Response (V): 5 - The client is oriented and able to engage in coherent conversation.Best Motor Response (M): 5 - The client can localize pain or follow motor commands (depending on additional context). The total GCS score would be 3 + 5 + 5 = 13, indicating a mild level of impairment or responsiveness.

Choice C Reason: This is incorrect because the client is able to make vocal sounds, as the GCS score for best verbal response is 5, which means the client can orient himself to person, place, and time.

Choice D Reason: This is incorrect because the client does not open his eyes when spoken to, as the GCS score for eye opening is 3, which means the client only opens his eyes in response to pain.

A. Contact the provider for further orders. B. Notify the blood bank of the discrepancy. C. Administer the blood as ordered. D. Complete an incident report.

Correct Answer is C

Explanation

Choice A: Contacting the provider for further orders is not necessary, because the client has type AB blood, which is compatible with any other blood type. The client can receive type B blood without any adverse reactions.

Choice B: Notifying the blood bank of the discrepancy is not required, because there is no discrepancy. The blood bank sent the correct type of blood for the client, according to their blood type.

Choice C: Administering the blood as ordered is the correct action, because type B blood is compatible with type AB blood. The client will not have any transfusion reactions or complications from receiving this type of blood.

Choice D: Completing an incident report is not appropriate, because there is no incident. The nurse did not make any error or mistake in administering the blood to the client. There is no need to document or report anything unusual.

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A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

Correct Answer is B

Explanation

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Correct Answer is C

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