Nokea
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 4 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client experiencing cardiac tamponade.
- A. Prepare the client for an immediate thoracentesis
- B. Obtain a prescription for an isotonic fluid bolus
- C. Perform frequent vital sign collection
- D. Obtain a prescription for intravenous furosemide
Correct Answer: C
Rationale: For cardiac tamponade, frequent vital sign collection (C) is indicated to monitor hemodynamic stability. Thoracentesis (A) is for pleural effusion, not pericardial fluid. Fluid bolus (B) may worsen tamponade by increasing pericardial pressure. Furosemide (D) is contraindicated as it reduces preload, which is already compromised.
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The nurse is planning a staff development conference about anaphylaxis. Which of the following information should the nurse include?
- A. 0.9% saline should be infused once vascular access is established.
- B. The initial treatment is intravenous diphenhydramine.
- C. The client should carry a prefilled syringe of hydrocortisone.
- D. If shock occurs, the client should be positioned in reverse Trendelenburg.
Correct Answer: A
Rationale: 0.9% saline infusion (A) is critical in anaphylaxis to restore volume in shock. Epinephrine, not diphenhydramine (B), is the initial treatment. Clients carry epinephrine (not hydrocortisone, C) in auto-injectors. Reverse Trendelenburg (D) is incorrect; flat or leg-elevated positioning is preferred.
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 3 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
The client is most likely experiencing ………………..
- A. acute coronary syndrome
- B. pneumothorax
- C. cardiac tamponade
Correct Answer: C
Rationale: Given the client's SLE history, chest pain, and lack of ST-elevations or troponin elevation, cardiac tamponade is the most likely diagnosis, as SLE can cause pericarditis leading to fluid accumulation. Acute coronary syndrome is less likely without ECG or troponin changes, and pneumothorax is not supported by the scenario.
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 2 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
Which of the following issues is the client at risk of developing? Select all that apply.
- A. cardiac tamponade
- B. cardiogenic shock
- C. stroke
- D. pneumothorax
- E. acute coronary syndrome
Correct Answer: A,B,C,E
Rationale: SLE increases the risk of cardiac tamponade (A) due to pericarditis, cardiogenic shock (B) from cardiac involvement, stroke (C) from antiphospholipid syndrome, and acute coronary syndrome (E) from accelerated atherosclerosis. Pneumothorax (D) is not a typical SLE complication.
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 5 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
The nurse prepares the client for an emergent pericardiocentesis and it is essential to have …………….. at the bedside. During the procedure, it is a priority for the nurse to monitor the client's ………….
- A. a bottle of sterile water
- B. a defibrillator
- C. positive pressure ventilation
- D. urinary output
- E. cardiac rhythm
- F. Gasaow coma scale
Correct Answer: B,E
Rationale: A defibrillator (B) is essential at the bedside during pericardiocentesis due to the risk of arrhythmias from needle insertion. Monitoring cardiac rhythm (E) is a priority to detect complications like ventricular arrhythmias. Sterile water (A), positive pressure ventilation (C), urinary output (D), and Glasgow Coma Scale (F) are not directly relevant.
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 6 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
The nurse teaches the client self-care practices for systemic lupus erythematosus (SLE). Which two (2) client statements indicate effective understanding?
- A. I should limit my exposure to direct sunlight to 45 continuous minutes each day.
- B. I should wear long sleeves and a large-brimmed hat when outdoors.
- C. I should wash my skin with an antibacterial soap.
- D. Cosmetics must be selected carefully and should include moisturizers and sun protectors.
- E. I should refrain from receiving any vaccine.
Correct Answer: B,D
Rationale: Wearing long sleeves and a large-brimmed hat (B) and using cosmetics with moisturizers and sun protectors (D) indicate understanding of photoprotection, crucial for SLE to prevent rash exacerbation. Limiting sun exposure to 45 minutes (A) is too specific and risky, antibacterial soap (C) is unnecessary, and avoiding all vaccines (E) is incorrect as some are safe.