The nurse obtains a pulmonary artery pressure reading of 25/12 mm Hg in a client recovering from a myocardial infarction. What is the nurse's first intervention?
a. Compare the results with previous read-ings.
b. Increase the IV fluid rate because these readings are low.
c. Immediately notify the physician of the elevated pressures.
d. Document the finding and continue to monitor.
A
Normal pulmonary artery pressures range from 15 to 26 mm Hg for systolic and from 5 to 15 mm Hg for diastolic. Although these readings are within normal limits, the nurse needs to assess any trends that may indicate a need for medical treatment to prevent complications.
You might also like to view...
A nurse is preparing a care plan for a client with limited English skills. The nurse has identified risk for impaired verbal communication as a nursing diagnosis. Which of the following interventions would be appropriate for this diagnosis?
A) Using an interpreter when communicating with the client B) Asking a family member to act as an interpreter C) Writing questions on a clip board for the client to read D) Speaking loud and slow when attempting to communicate with the client
A patient has undergone a wide excision of the vulva. Which of the following would be contraindicated in the immediate postoperative period?
A) Placing patient in low-Fowler's position B) Application of compression stockings C) Ambulation to a chair in the immediate postoperative period D) Low-residue diet
The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?
a. Refer for immediate medical evaluation. b. Continue assessment to determine cause of neck pain. c. Ask parent when neck was injured. d. Record "head lag" on assessment record, and continue assessment of child.
In placing precordial leads, be sure to affix all the electrodes on the left side of the sternum with the exception of which lead??
A) Lead V3 B) Lead V4 C) Lead V2 D) Lead V1