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?
a. Position the patient supine at all times.
b. Avoid the use of anticoagulant medications.
c. Measure the patient's urinary output every hour.
d. Provide passive range of motion for all extremities.
ANS: C
Monitoring urine output will help determine whether the patient's cardiac output has improved and also help monitor for balloon displacement. The head of the bed can be elevated up to 30 degrees. Heparin is used to prevent thrombus formation. Limited movement is allowed for the extremity with the balloon insertion site to prevent displacement of the balloon.
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