Nokea
A nurse assesses clients on a cardiac unit. Which clients should the nurse identify as at greatest risk for the development of acute pericarditis?
- A. A 36-year-old woman with systemic lupus erythematosus (SLE)
- B. A 52-year-old woman recovering from a myocardial infarction
- C. A 59-year-old woman recovering from cardiac surgery
- D. An 80-year-old man with a bacterial infection of the respiratory tract
- E. An 80-year-old woman with a stage III sacral ulcer
Correct Answer: A,B,D
Rationale: Acute pericarditis is associated with systemic connective tissue diseases like SLE, post-myocardial infarction (Dressler's syndrome), post-cardiac surgery inflammation, and bacterial infections. Stage III sacral ulcers do not increase the risk.
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A nurse prepares to discharge a client who has heart failure. Spice questions should the nurse ask to ensure the client's safety at home?
- A. Are your bedroom and bathroom on the first floor?
- B. What social support do you have at home?
- C. What is your typical daily diet?
- D. What spiritual beliefs may impact your recovery?
- E. Are you able to accurately weigh yourself at home?
Correct Answer: A,B,D
Rationale: To ensure safety, the nurse should assess structural barriers (e.g., bedroom/bathroom location), social support, and the ability to weigh daily for fluid monitoring. Diet and spiritual beliefs are relevant but not directly tied to safety.
After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for additional teaching?
- A. I'll be able to carry heavy loads after 6 months of rest
- B. I will have my teeth cleaned by my dentist in 2 weeks
- C. I must avoid eating foods high in vitamin K
- D. I will use an electric razor for shaving
Correct Answer: B
Rationale: Clients who have defective or repaired valves are at high risk for endocarditis. The client should avoid dental procedures for 6 months because of the risk for endocarditis. The other statements reflect correct understanding of post-surgery care.
A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the priority nursing intervention?
- A. Oxygen saturation of 90%
- B. Dyspnea on exertion
- C. Mild systolic murmurs
- D. Upper extremity weakness
Correct Answer: B
Rationale: Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other manifestations do not directly indicate the progression of mitral valve stenosis.
A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect?
- A. Hematocrit: 32.8%
- B. Serum sodium: 130 mEq/L
- C. Serum potassium: 5.8 mEq/L
- D. B-type natriuretic peptide: 1123 pg/mL
- E. Creatinine: 2.1 mg/dL
Correct Answer: A,B,C,D,E
Rationale: Heart failure can cause hemodilution (low hematocrit), hyponatremia (low sodium), hyperkalemia (high potassium), elevated B-type natriuretic peptide (indicating heart strain), and elevated creatinine (indicating renal dysfunction due to reduced cardiac output).
A nurse admits a client who is experiencing an exacerbation of heart failure. Which action should the nurse take first?
- A. Assess the client's respiratory status
- B. Draw blood for sodium electrolytes
- C. Administer intravenous furosemide (Lasix)
- D. Ask the client about current medications
Correct Answer: A
Rationale: Assessment of respiratory and oxygenation status is the priority nursing intervention for the prevention of complications in heart failure exacerbation. Monitoring electrolytes, administering diuretics, and asking about medications are important but do not take priority over assessing respiratory status.