Which determination is the nurse trying to achieve by monitoring a patient's cardiac output?
Presence of cardiac dysrhythmias
Peripheral extremity circulation
Oxygenation requirements
Ventilation status
The Correct Answer is C
A. While monitoring cardiac output can provide insights into heart function, it does not directly determine the presence of dysrhythmias.
B. Peripheral extremity circulation is influenced by cardiac output but is not the primary focus of monitoring it.
C. Cardiac output is essential for determining the heart's ability to meet the body's oxygenation requirements; low cardiac output can lead to inadequate oxygen delivery.
D. Ventilation status refers to the respiratory function and is not directly assessed through cardiac output measurements.
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Correct Answer is D
Explanation
A. Sequential compression devices are used to prevent deep vein thrombosis and are not relevant for assessing orthostatic hypotension.
B. Elastic stockings are used to promote venous return and prevent edema, not for measuring blood pressure.
C. A thermometer measures body temperature and does not provide information on blood pressure or orthostatic changes.
D. A blood pressure cuff is essential for assessing orthostatic hypotension. The nurse will measure blood pressure while the patient is supine, sitting, and standing to determine any significant changes that occur with position changes.
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.