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 A

Explanation

A. Numbness and tingling in the left hand could indicate compromised blood flow or nerve damage, potentially due to the arterial line, requiring immediate assessment and intervention.

B. Slight bloody drainage is a common finding and typically does not require immediate action.

C. A dressing beginning to lift should be addressed to maintain a sterile environment but is not an emergency.

D. Slight redness at the insertion site may indicate mild irritation or early signs of infection, but it does not require immediate intervention compared to the potential vascular or nerve compromise suggested by numbness and tingling.

A. "Most religions support organ donation, so don't let that stand in the way." B. "There is such a shortage of organs in this country, so I think you should go ahead and consent to donate your spouse's organs." C. "Don't you think you will feel a little better about the situation if you donate your spouse's organs?" D. "What do you think your spouse would have wanted?"

Correct Answer is D

Explanation

A. This response may make the spouse feel pressured by implying that religion should not be a concern, which may not be respectful of the spouse's beliefs.

B. This statement is coercive, focusing on the shortage of organs rather than on the spouse's feelings and the wishes of the deceased.

C. Suggesting that donating organs will make the spouse feel better can be seen as manipulative and may not truly address the spouse's confusion or emotions.

D. Asking what the spouse thinks the deceased would have wanted is appropriate, as it centers on the values and wishes of the deceased, which can guide the spouse in making an informed decision.

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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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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?

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Explanation

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Explanation

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