Nokea
A client is admitted to the hospital with a diagnosis of acute bacterial pericarditis. Which nursing assessment findings are associated with this form of heart disease? Select all that apply.
- A. Fever
- B. Leukopenia
- C. Bradycardia
- D. Pericardial friction rub
- E. Decreased erythrocyte sedimentation rate
- F. Precordial chest pain that intensifies by the supine position
Correct Answer: A,D,F
Rationale: In acute bacterial pericarditis, the membranes surrounding the heart become inflamed and rub against each other, producing the classic pericardial friction rub. Fever typically occurs and is accompanied by leukocytosis and an elevated erythrocyte sedimentation rate. The client complains of severe precordial chest pain that intensifies when lying supine and decreases in a sitting position. The pain also intensifies when the client breathes deeply. Malaise, myalgia, and tachycardia are common.
You may also like to solve these questions
A client, experiencing a sudden onset of chest pain and dyspnea, is diagnosed with a pulmonary embolus. Which expected prescription should the nurse immediately implement for this client? Select all that apply.
- A. Supplemental oxygen
- B. High Fowler's position
- C. Semi-Fowler's position
- D. Morphine sulfate intravenously
- E. Two tablets of acetaminophen with codeine
- F. Meperidine hydrochloride intravenously
Correct Answer: A,C,D
Rationale: Standard therapeutic intervention for the client with pulmonary embolus includes proper positioning, oxygen, and intravenous analgesics. The head of the bed is placed in semi-Fowler's position. Fowler's is avoided because extreme hip flexure slows venous return from the legs and increases the risk of new thrombi. The usual analgesic of choice is morphine sulfate administered intravenously. This medication reduces pain, alleviates anxiety, and can diminish congestion of blood in the pulmonary vessels because it causes peripheral venous dilation.
A client who underwent surgical repair of an abdominal aortic aneurysm is 1 day postoperative. The nurse performs an abdominal assessment and notes the absence of bowel sounds. What action should the nurse take?
- A. Start the client on sips of water.
- B. Remove the nasogastric (NG) tube.
- C. Call the primary health care provider immediately.
- D. Document the finding and continue to assess for bowel sounds.
Correct Answer: D
Rationale: Bowel sounds may be absent for 3 to 4 postoperative days because of bowel manipulation during surgery. The nurse should document the finding and continue to monitor the client. The NG tube should stay in place if present, and the client is kept NPO until after the onset of bowel sounds. Additionally, the nurse does not remove the tube without a prescription to do so. There is no need to call the primary health care provider immediately at this time.
The nurse caring for a client receiving intravenous therapy monitors for which signs of infiltration of an intravenous (IV) infusion? Select all that apply.
- A. Slowing of the IV rate
- B. Tenderness at the insertion site
- C. Edema around the insertion site
- D. Skin tightness at the insertion site
- E. Warmth of skin at the insertion site
- F. Fluid leaking from the insertion site
Correct Answer: A,B,C,D,F
Rationale: Infiltration is the leakage of an IV solution into the extravascular tissue. Manifestations include slowing of the IV rate; burning, tenderness, or general discomfort at the insertion site; increasing edema in or around the catheter insertion site; complaints of skin tightness; blanching or coolness of the skin; and fluid leaking from the insertion site.
Twelve hours after delivery, the nurse assesses the client for uterine involution. The nurse determines that the uterus is progressing normally toward its prepregnancy state when palpation of the client's fundus is at which level?
- A. At the umbilicus
- B. One finger breadth below the umbilicus
- C. Two finger breadths below the umbilicus
- D. Midway between the umbilicus and the symphysis pubis
Correct Answer: A
Rationale: The term 'involution' is used to describe the rapid reduction in size and the return of the uterus to a normal condition similar to its nonpregnant state. Immediately after the delivery of the placenta, the uterus contracts to the size of a large grapefruit. The fundus is situated in the midline between the symphysis pubis and the umbilicus. Within 6 to 12 hours after birth, the fundus of the uterus rises to the level of the umbilicus. The top of the fundus remains at the level of the umbilicus for about a day and then descends into the pelvis approximately one finger breadth on each succeeding day.
The nurse assesses the client diagnosed with acquired immunodeficiency syndrome (AIDS) for early signs of Kaposi's sarcoma. What characteristics would be consistent with that lesion? Select all that apply.
- A. Flat
- B. Raised
- C. Resembling a blister
- D. Light blue in color
- E. Brownish and scaly in appearance
- F. Color varies from pink to dark violet or black
Correct Answer: A,F
Rationale: Kaposi's sarcoma generally starts with an area that is flat and pink that changes to a dark violet or black color. The lesions are usually present bilaterally. They may appear in many areas of the body and are treated with radiation, chemotherapy, and cryotherapy. None of the other options are associated with this type of lesion.