Nokea
Cardiac tamponade is suspected in a patient who has acute pericarditis. Which of the following actions should the nurse implement to assess for the presence of pulsus paradoxus?
- A. Check the electrocardiogram (ECG) for variations in rate in relation to inspiration and expiration
- B. Note when Korotkoff sounds are audible during both inspiration and expiration.
- C. Auscultate for a pericardial friction rub that increases in volume during inspiration.
- D. Subtract the diastolic blood pressure (DBP) from the systolic blood pressure (SBP).
Correct Answer: B
Rationale: Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when Korotkoff sounds can be heard during only expiration and when they can be heard throughout the respiratory cycle. The other methods described would not be useful in determining the presence of pulsus paradoxus.
You may also like to solve these questions
The nurse is caring for a patient with infective endocarditis of the tricuspid valve. Which of the following findings should the nurse plan to monitor for the presence of endocarditis in the patient?
- A. Dyspnea
- B. Flank pain
- C. Hemiparesis
- D. Splenomegaly
Correct Answer: A
Rationale: Embolization from the tricuspid valve would cause symptoms of pulmonary embolus. Flank pain, hemiparesis, and splenomegaly would be associated with embolization from the left-sided valves.
The nurse is assessing a patient with mitral valve stenosis and hypoxemia. Which of the following findings should the nurse expect to assess?
- A. Diastolic murmur
- B. Peripheral edema
- C. Right upper quadrant tenderness
- D. Complaints of shortness of breath
Correct Answer: D
Rationale: The pressure gradient changes in mitral stenosis lead to fluid backup into the lungs, resulting in hypoxemia and dyspnea. The other findings also may be associated with mitral valve disease, but are not indicators of possible hypoxemia.
The nurse is caring for a patient with aortic stenosis and establishes a nursing diagnosis of acute pain related to decreased coronary blood flow. Which of the following interventions is best?
- A. Promote rest to decrease myocardial oxygen demand.
- B. Educate the patient about the need for anticoagulant therapy.
- C. Teach the patient to use sublingual nitroglycerin for chest pain.
- D. Elevate the head of the bed 60 degrees to decrease venous return
Correct Answer: A
Rationale: Rest is recommended to balance myocardial oxygen supply and demand and to decrease chest pain. The patient with aortic stenosis requires higher preload to maintain cardiac output, so nitroglycerin and measures to decrease venous return are contraindicated. Anticoagulation is not recommended unless the patient has atrial fibrillation.
The nurse is planning care for a patient hospitalized with a streptococcal infective endocarditis (IE). Which of the following interventions should the nurse anticipate?
- A. Monitor laboratories for streptococcal antibodies.
- B. Arrange for insertion of a long-term IV catheter.
- C. Encourage the patient to get regular aerobic exercise.
- D. Teach the importance of completing all oral antibiotics.
Correct Answer: B
Rationale: Treatment for IE involves 4-6 weeks of IV antibiotic therapy in order to eradicate the bacteria, which will require a long-term IV catheter such as a peripherally inserted central catheter (PICC) line. Rest periods and limiting physical activity to a moderate level are recommended during the treatment for IE. Oral antibiotics are not effective in eradicating the infective bacteria that cause IE. Blood cultures, rather than antibody levels, are used to monitor the effectiveness of antibiotic therapy.
Which of the following assessment information obtained by the nurse for a patient with aortic stenosis is most important to report to the health care provider?
- A. The patient complains of chest pain associated with ambulation.
- B. A loud systolic murmur is audible along the right sternal border.
- C. A thrill is palpable at the 2nd intercostal space, right sternal border.
- D. The point of maximum impulse (PMI) is at the left midclavicular line.
Correct Answer: A
Rationale: Chest pain occurring with aortic stenosis is caused by cardiac ischemia, and reporting this information would be a priority. A systolic murmur and thrill are expected in a patient with aortic stenosis. A PMI at the left midclavicular line is normal.