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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The radial pulse is not as reliable as the carotid pulse in assessing circulation during CPR.
B. The carotid pulse is the most reliable site to assess circulation in an adult during CPR because it is closest to the heart and will reflect the true status of central circulation.
C. The apical pulse is not typically assessed during CPR due to its location and difficulty in palpation.
D. The popliteal pulse is not a recommended site for assessing circulation during CPR.
Correct Answer is C
Explanation
A. Secondary hypertension is high blood pressure due to an identifiable cause, such as renal disease, but it does not describe an acute situation with target organ damage.
B. Hypertensive urgency is a situation where the blood pressure is severely elevated but without evidence of target organ damage.
C. Hypertensive emergency is characterized by severely elevated blood pressure with evidence of acute target organ damage, such as encephalopathy, myocardial infarction, or renal failure, requiring immediate medical intervention.
D. Primary hypertension, also known as essential hypertension, is high blood pressure without a known secondary cause and does not describe an acute emergency.
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