Nokea
A patient has undergone a successful heart transplant and has been discharged home with a medication regimen that includes cyclosporine and tacrolimus. In light of this patients medication regimen, what nursing diagnosis should be prioritized?
- A. Risk for injury
- B. Risk for infection
- C. Risk for peripheral neurovascular dysfunction
- D. Risk for unstable blood glucose
Correct Answer: B
Rationale: Immunosuppressants decrease the bodys ability to resist infections, and a satisfactory balance must be achieved between suppressing rejection and avoiding infection. These drugs do not create a heightened risk of injury, neurovascular dysfunction, or unstable blood glucose levels.
You may also like to solve these questions
The nurse is reviewing the echocardiography results of a patient who has just been diagnosed with dilated cardiomyopathy (DCM). What changes in heart structure characterize DCM?
- A. Dilated ventricles with atrophy of the ventricles
- B. Dilated ventricles without hypertrophy of the ventricles
- C. Dilation and hypertrophy of all four heart chambers
- D. Dilation of the atria and hypertrophy of the ventricles
Correct Answer: B
Rationale: DCM is characterized by significant dilation of the ventricles without significant concomitant hypertrophy and systolic dysfunction. The ventricles do not atrophy in patients with DCM.
The nurse on the hospitals infection control committee is looking into two cases of hospital-acquired infective endocarditis among a specific classification of patients. What classification of patients would be at greatest risk for hospital-acquired endocarditis?
- A. Hemodialysis patients
- B. Patients on immunoglobulins
- C. Patients who undergo intermittent urinary catheterization
- D. Children under the age of 12
Correct Answer: A
Rationale: Hospital-acquired infective endocarditis occurs most often in patients with debilitating disease or indwelling catheters and in patients who are receiving hemodialysis or prolonged IV fluid or antibiotic therapy. Patients taking immunosuppressive medications or corticosteroids are more susceptible to fungal endocarditis. Patients on immunoglobulins, those who need in and out catheterization, and children are not at increased risk for nosocomial infective endocarditis.
A patient is a candidate for percutaneous balloon valvuloplasty, but is concerned about how this procedure will affect her busy work schedule. What guidance should the nurse provide to the patient?
- A. Patients generally stay in the hospital for 6 to 8 days.
- B. Patients are kept in the hospital until they are independent with all aspects of their care.
- C. Patients need to stay in the hospital until they regain normal heart function for their age.
- D. Patients usually remain at the hospital for 24 to 48 hours.
Correct Answer: D
Rationale: After undergoing percutaneous balloon valvuloplasty, the patient usually remains in the hospital for 24 to 48 hours. Prediagnosis levels of heart function are not always attainable and the patient does not need to be wholly independent prior to discharge.
A patient who has recently recovered from a systemic viral infection is undergoing diagnostic testing for myocarditis. Which of the nurses assessment findings is most consistent with myocarditis?
- A. Sudden changes in level of consciousness (LOC)
- B. Peripheral edema and pulmonary edema
- C. Pleuritic chest pain
- D. Flulike symptoms
Correct Answer: D
Rationale: The most common symptoms of myocarditis are flulike. Chest pain, edema, and changes in LOC are not characteristic of myocarditis.
A patient has been diagnosed with a valvular disorder. The patient tells the nurse that he has read about numerous treatment options, including valvuloplasty. What should the nurse teach the patient about valvuloplasty?
- A. For some patients, valvuloplasty can be done in a cardiac catheterization laboratory.
- B. Valvuloplasty is a dangerous procedure, but it has excellent potential if it goes well.
- C. Valvuloplasty is open heart surgery, but this is very safe these days and normally requires only an overnight hospital stay.
- D. Its prudent to get a second opinion before deciding to have valvuloplasty.
Correct Answer: A
Rationale: Some valvuloplasty procedures do not require general anesthesia or cardiopulmonary bypass and can be performed in a cardiac catheterization laboratory or hybrid room. Open heart surgery is not required and the procedure does not carry exceptional risks that would designate it as being dangerous. Normally there is no need for the nurse to advocate for a second opinion.