The nurse is caring for a patient who has an intraaortic balloon pump in place. Which action should be included in the plan of care?

Provide passive range of motion for all extremities.

Position the patient supine with head flat at all times.

Measure the patient's urinary output every hour.

Avoid the use of anticoagulant medications.

Answer and Explanation

The Correct Answer is C

A. Passive range of motion may be performed, but it is not the priority in this situation.

B. The head of the bed should be elevated 30 degrees or less, not necessarily flat, to prevent complications.

C. Hourly urinary output measurement is essential because the intra-aortic balloon pump (IABP) can impair renal perfusion, and monitoring urine output helps assess renal function.

D. Anticoagulants are often necessary to prevent clot formation associated with the IABP, so avoiding them is not advised unless contraindicated.

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Correct Answer is C

Explanation

A. Quickly removing the family members may add to their distress and does not respect their right to decide.

B. Telling them it will be stressful assumes their reaction without giving them a choice.

C. Allowing the family members to choose whether to stay respects their autonomy and can provide comfort during a difficult time. It is also in line with current best practices for family presence during resuscitation.

D. Assigning a staff member to wait outside is appropriate but should be done after offering the family the option to stay in the room.

A. Deaths from patients with communicable diseases do not need to be reported to organ procurement agencies. B. Tissue donation is involuntary. C. Organ donation can be authorized by a client's surrogate. D. Each organ donation request should be reported to a facility's committee.

Correct Answer is C

Explanation

A. Deaths of patients with communicable diseases still need to be reported because tissue and organ viability must be assessed on a case-by-case basis.

B. Tissue donation is voluntary and requires consent from the patient or their legal representative.

C. Organ donation can be authorized by a client's surrogate if the client has not previously given or refused consent. This allows for the surrogate to make decisions in line with the client’s wishes or best interests.

D. While facilities may have committees involved in the process, reporting is to organ procurement organizations, not solely to a facility's committee.

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A nurse is caring for a client in the emergency department (ED).

<div id="exhibits">Exhibits</div>

The nurse is planning care for the client. For each potential prescription, indicate whether it is an anticipated (high priority), nonessential (low priority), contraindicated(unrelated).

Select one or more in each option.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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