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A client is admitted to the hospital with a diagnosis of pericarditis. The nurse reviews the client's record for which sign or symptom that differentiates pericarditis from other cardiopulmonary problems?
- A. Anterior chest pain
- B. Pericardial friction rub
- C. Weakness and irritability
- D. Chest pain that worsens with inspiration
Correct Answer: B
Rationale: Pericardial friction rub is a distinctive sign of pericarditis, characterized by a scraping or grating sound heard on auscultation, which helps differentiate pericarditis from other cardiopulmonary conditions. Anterior chest pain may be present in various cardiopulmonary issues. Weakness and irritability are nonspecific symptoms, and chest pain worsening with inspiration is more indicative of pleuritic conditions.
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A client with deep vein thrombosis (DVT) is receiving anticoagulant therapy. The nurse should reinforce with the client the importance of reporting which potential side effect?
- A. Nausea
- B. Headache
- C. Gingival bleeding
- D. Dizziness
Correct Answer: C
Rationale: Gingival bleeding is a common side effect of anticoagulant therapy. Anticoagulants work by prolonging the time it takes for blood to clot, which can lead to bleeding issues, including gingival bleeding. Since bleeding, including gingival bleeding, can be a serious side effect that requires medical attention, the client should be educated on reporting it promptly to their healthcare provider.
The client's B-type natriuretic peptide (BNP) level is 691 pg/mL. Which intervention should the nurse implement when providing care for the client?
- A. Take daily weights and monitor trends.
- B. Encourage fluid intake to improve hydration.
- C. Elevate the legs above the level of the heart.
- D. Position the client supine with the head of the bed at 30 degrees.
Correct Answer: A
Rationale: Elevated BNP levels are indicative of heart failure, which often causes fluid retention and weight gain. Taking daily weights and monitoring trends allows the nurse to assess for changes in fluid status. This intervention helps in evaluating the effectiveness of the treatment plan and identifying worsening heart failure symptoms early.
The LPN/LVN is assisting in caring for a client in the telemetry unit and is monitoring the client for cardiac changes indicative of hypokalemia. Which occurrence noted on the cardiac monitor indicates the presence of hypokalemia?
- A. Tall, peaked T waves
- B. ST-segment depression
- C. Prolonged P-R interval
- D. Widening of the QRS complex
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a diagnosis of angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions?
- A. I am considering cutting my workload.
- B. I need to cut down on cigarette smoking.
- C. I am so relieved that my heart is repaired.
- D. I need to adhere to my dietary restrictions.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client is being ambulated due to activity intolerance caused by bacterial endocarditis. How can the nurse determine that the client is best tolerating ambulation?
- A. Mild dyspnea after walking 10 feet
- B. Minimal chest pain rated 1 on a 1-to-10 pain scale
- C. Pulse rate that increases from 68 to 94 beats per minute
- D. Blood pressure that increases from 114/82 to 118/86 mm Hg
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.