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 D

Explanation

A. Documentation of waveform values is important but does not directly enhance patient safety during monitoring.

B. Limiting the pressure tubing length can help maintain accuracy, but it is not the primary safety measure.

C. Zero referencing is crucial for accurate readings, but it must be done in conjunction with ensuring alarms are active.

D. Ensuring that alarm limits are turned on and appropriately set is the best safety measure to immediately alert the nurse to any critical changes in the patient's status.

A. "The catheter will be in position until the heart has a chance to heal." B. The catheter will allow the provider to better manage fluid therapy." C. "The catheter tip comes to rest inside my brother's left ventricle." D. "The catheter will provide multiple IV sites to give intravenous fluid."

Correct Answer is B

Explanation

A. While a CVP catheter might be in place for an extended period, its purpose is not directly related to heart healing.

B. The CVP catheter is used to monitor central venous pressure, which helps guide fluid management and assess right heart function.

C. The CVP catheter does not extend into the left ventricle; it is typically positioned in the superior vena cava or right atrium.

D. The CVP catheter may have multiple lumens for administering fluids, but its primary purpose is hemodynamic monitoring, not just providing IV access.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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