The nurse suspects the patient has increased cardiac afterload. Which piece of equipment should the nurse obtain to determine the presence of this condition?
Yankauer suction tip catheter
Blood pressure cuff
Oxygen cannula
Pulse oximeter
The Correct Answer is B
A. A Yankauer suction tip catheter is used for suctioning secretions and does not assess cardiac function or afterload.
B. A blood pressure cuff is essential for measuring blood pressure, which can indicate increased afterload through elevated systemic vascular resistance.
C. An oxygen cannula is used for delivering supplemental oxygen and does not provide information about cardiac afterload.
D. A pulse oximeter measures oxygen saturation, which is not directly related to assessing cardiac afterload.
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Correct Answer is B
Explanation
A. A Yankauer suction tip catheter is used for suctioning secretions and does not assess cardiac function or afterload.
B. A blood pressure cuff is essential for measuring blood pressure, which can indicate increased afterload through elevated systemic vascular resistance.
C. An oxygen cannula is used for delivering supplemental oxygen and does not provide information about cardiac afterload.
D. A pulse oximeter measures oxygen saturation, which is not directly related to assessing cardiac afterload.
Correct Answer is A
Explanation
A. "Acute pain" is a NANDA-I approved nursing diagnosis that identifies a specific condition that nursing interventions can address.
B. "Sore throat" is a symptom rather than a nursing diagnosis and does not appear in NANDA-I.
C. "Sleep apnea" is classified as a medical diagnosis and not as a nursing diagnosis within NANDA-I.
D. "Heart failure" is also a medical diagnosis and not an approved nursing diagnosis, as it describes a condition rather than the patient's response or nursing concerns.