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The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. Which of the following actions is best for the nurse to implement?
- A. Force fluids to 3000 ml to decrease fever and inflammation.
- B. Teach about deep, slow respirations to control the pain.
- C. Remind the patient to ask for the opioid pain medication every 4 hours.
- D. Position the patient in Fowler's position, leaning forward on the overbed table.
Correct Answer: D
Rationale: Sitting upright and leaning forward frequently will decrease the pain associated with pericarditis. Forcing fluids will not decrease the inflammation or pain. Taking deep respirations tends to increase pericardial pain. Opioids are not very effective at controlling pain caused by acute inflammatory conditions and are usually ordered PRN. The patient would receive scheduled doses of a nonsteroidal anti-inflammatory drug (NSAID).
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The nurse is caring for a patient who had an acute myocardial infarction (MI) 3 days prior and has symptoms of stabbing chest pain that increases with deep breathing. Which of the following actions should the nurse take first?
- A. Auscultate the heart sounds.
- B. Check the patient's oral temperature.
- C. Notify the patient's health care provider.
- D. Give the ordered acetaminophen.
Correct Answer: A
Rationale: The patient's clinical manifestations and history are consistent with pericarditis, and the first action by the nurse should be to listen for a pericardial friction rub. Checking the temperature, giving acetaminophen, and notifying the health care provider also are appropriate actions but would not be done before listening for a rub.
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 providing discharge teaching for a patient with mitral valve prolapse (MVP) without valvular regurgitation. Which of the following patient statements indicate that teaching has been effective?
- A. Plan to take antibiotics before any dental appointments.
- B. Limit physical activity to avoid stressing the heart valves.
- C. Take one Aspirin a day to prevent embolization from the valve.
- D. Avoid use of over-the-counter (OTC) medications that contain stimulant drugs.
Correct Answer: D
Rationale: Use of stimulant medications should be avoided by patients with MVP since these may exacerbate symptoms. Daily Aspirin and restricted physical activity are not needed by patients with mild MVP. Antibiotic prophylaxis is needed for patients with MVP with regurgitation but will not be necessary for this patient.
The nurse is conducting postoperative teaching with a patient who had a mitral valve replacement with a mechanical valve. Which of the following information should the nurse include in the teaching plan?
- A. Use of daily Aspirin for anticoagulation
- B. Correct method for taking the radial pulse
- C. Need for frequent laboratory blood testing
- D. Possibility of valve replacement in 7-10 years
Correct Answer: C
Rationale: Anticoagulation therapy with warfarin is needed for a patient with mechanical valves to prevent clotting on the valve; this will require frequent international normalized ratio (INR) testing. Daily Aspirin use will not be effective in reducing risk for clots on the valve. Mechanical valves are durable and would last longer than 7-10 years. Monitoring of the radial pulse is not necessary after valve replacement.
The nurse establishes the nursing diagnosis of ineffective health maintenance related to lack of knowledge concerning long-term management of rheumatic fever when a patient who is recovering from rheumatic fever says which of the following statements?
- A. I will need to have monthly antibiotic injections for 10 years or longer.
- B. I will need to take Aspirin or ibuprofen to relieve my joint pain.
- C. I will call the doctor if I develop excessive fatigue or difficulty breathing.
- D. I will be immune to further episodes of rheumatic fever after this infection.
Correct Answer: D
Rationale: Patients with a history of rheumatic fever are more susceptible to a second episode. The other patient statements are correct and would not support the nursing diagnosis of ineffective health maintenance.