Nokea
The client diagnosed with pericarditis is being discharged home. Which intervention should the nurse include in the discharge teaching?
- A. Be sure to allow for uninterrupted rest and sleep.
- B. Refer the client to outpatient occupational therapy.
- C. Maintain oxygen via nasal cannula at two (2) L/min.
- D. Discuss upcoming valve replacement surgery.
Correct Answer: A
Rationale: Rest and sleep (A) reduce cardiac demand in pericarditis. Occupational therapy (B), oxygen (C), and valve surgery (D) are not indicated.
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Which assessment finding is the best indication that oxygen therapy is effective?
- A. The client's face is flushed.
- B. Capillary refill is 6 seconds.
- C. The client states, 'I'm feeling better.'
- D. The apical pulse is less bounding.
Correct Answer: C
Rationale: The client's subjective improvement in symptoms indicates effective oxygen therapy.
The nurse is caring for a client who goes into ventricular tachycardia. Which intervention should the nurse implement first?
- A. Call a code immediately.
- B. Assess the client for a pulse.
- C. Begin chest compressions.
- D. Continue to monitor the client.
Correct Answer: B
Rationale: Ventricular tachycardia requires assessing for a pulse (B) to determine if it’s pulseless (needing CPR, C) or stable (medication). Calling a code (A) or monitoring (D) depends on pulse status.
The nursing team develops a care plan and expected outcomes for the client's recovery. Which expected outcomes are most important? Select all that apply.
- A. The client will not gain weight.
- B. The client will not gain weight.
- C. The client will comply with the dietary restrictions.
- D. The client will avoid any alcoholic beverages.
- E. The client will verbalize fears and anxieties freely.
- F. The client will maintain pressure over the intravenous site.
Correct Answer: C,D,E
Rationale: Complying with dietary restrictions, avoiding alcohol, and verbalizing fears support recovery by reducing cardiac risk and addressing emotional needs.
After the client has been successfully resuscitated by the nurse, which body position is most correct while awaiting transfer to the emergency department?
- A. Supine with the head elevated
- B. On the side upper knee flexed
- C. Prone with the head lowered
- D. Flat with the knees extended
Correct Answer: D
Rationale: Flat with knees extended ensures airway patency and circulation stability post-resuscitation.
Which statement by the nurse is the best explanation for why the client needs to take the prescribed medication?
- A. It may destroy the virus causing your disease.
- B. It may reduce the scar tissue on the valve.
- C. It may stop blood clots from forming.
- D. It may prevent future bacterial infections.
Correct Answer: D
Rationale: Nafcillin is an antibiotic used to prevent bacterial endocarditis in valvular disease.