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The client with pericarditis asks why they hear a rubbing sound. What is the best response?
- A. It's caused by fluid in your lungs.
- B. It's due to inflammation of the heart's lining.
- C. It's a normal heart sound.
- D. It's from high blood pressure.
Correct Answer: B
Rationale: A pericardial friction rub is caused by inflamed pericardial layers rubbing together.
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The nurse is preparing a client for cardioversion. Which instruction is most important?
- A. You will be awake during the procedure.
- B. You must not eat for 4 hours after.
- C. You will receive sedation before the procedure.
- D. You can resume normal activity immediately.
Correct Answer: C
Rationale: Sedation is used during cardioversion to ensure comfort and amnesia during the procedure.
Which teaching point should the nurse include for a client with endocarditis? Select all that apply.
- A. Report fever or chills immediately.
- B. Brush teeth gently to avoid gum bleeding.
- C. Avoid sharing toothbrushes.
- D. Take antibiotics for the full course.
- E. Monitor for signs of heart failure.
- F. Limit physical activity during treatment.
Correct Answer: A,B,C,D,E,F
Rationale: Reporting symptoms, gentle oral hygiene, avoiding shared items, completing antibiotics, monitoring heart failure, and limiting activity prevent complications.
The client with a left-sided mastectomy is diagnosed with elephantiasis of the left arm. Which signs/symptoms should the nurse expect to assess?
- A. Edematous arm from the axillary area to the fingertips.
- B. Painful, edematous, reddened lower forearm.
- C. Tented skin turgor over the entire left arm.
- D. Nipple retraction and peau d’orange skin.
Correct Answer: A
Rationale: Elephantiasis causes chronic lymphedema, leading to arm edema from axilla to fingertips (A). Pain/redness (B) suggests infection, tented turgor (C) is dehydration, and nipple changes (D) are breast cancer signs.
Which interventions should the nurse discuss with the client diagnosed with atherosclerosis? Select all that apply.
- A. Include the significant other in the discussion.
- B. Stop smoking or using any type of tobacco products.
- C. Maintain a sedentary lifestyle as much as possible.
- D. Avoid stressful situations.
- E. Daily isometric exercises are important.
Correct Answer: A,B,D
Rationale: Including significant other (A), stopping smoking (B), and avoiding stress (D) reduce atherosclerosis risk. Sedentary lifestyle (C) worsens it, and isometric exercises (E) increase BP.
The nurse is monitoring a client with atrial fibrillation. Which finding is most concerning?
- A. Heart rate of 110 beats per minute
- B. Blood pressure of 140/90 mmHg
- C. Dizziness and shortness of breath
- D. Oxygen saturation of 95%
Correct Answer: C
Rationale: Dizziness and shortness of breath suggest hemodynamic instability, which is concerning in atrial fibrillation.