Nokea
The nurse is caring for a client diagnosed with acute pericarditis. Which complication is the client at risk for developing?
- A. cardiac tamponade
- B. hemothorax
- C. pulmonary embolism
- D. tension pneumothorax
Correct Answer: A
Rationale: Acute pericarditis can lead to pericardial effusion, which may progress to cardiac tamponade, compressing the heart.
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Which of the following statements correctly outlines the proper flow of blood through the heart?
- A. Superior and Inferior vena cavas → Right atrium → Tricuspid valve → Right ventricle → Pulmonary valve → Pulmonary artery → Lungs → Pulmonary veins → Left atrium → Mitral valve → Left ventricle → Aortic valve → Aorta → Systemic circulation
- B. Superior and Inferior vena cavas → Right atrium → Mitral valve → Right ventricle → Pulmonary valve → Pulmonary artery → Lungs → Pulmonary veins → Left atrium → Tricuspid valve → Left ventricle → Aortic valve → Aorta → Systemic circulation
- C. Superior and Inferior vena cavas → Right atrium → Tricuspid valve → Right ventricle → Pulmonary valve → Pulmonary veins → Lungs → Pulmonary artery → Left atrium → Mitral valve → Left ventricle → Aortic valve → Aorta → Systemic circulation
- D. Superior and Inferior vena cavas → Right atrium → Tricuspid valve → Right ventricle → Aortic valve → Pulmonary veins → Lungs → Pulmonary artery → Left atrium → Mitral valve → Left ventricle → Pulmonary valve → Aorta → Systemic circulation
Correct Answer: A
Rationale: This sequence accurately describes blood flow: deoxygenated blood enters the right heart, is pumped to the lungs, and oxygenated blood returns to the left heart for systemic circulation.
The following scenario applies to the next 6 items
The client is a 72-year-old male who presents to the emergency department with increasing
shortness of breath over the past two days that gets worse when he is lying flat in bed at night.
Item 1 of 6
History And Physical Nurses' Notes Flow Sheet
0700: The client is a 72-year-old male who presents to the emergency department with increasing shortness of breath over the past two days that gets worse when he is lying flat in bed at night. He states, "I feel like I can't catch my breath," and he had to sleep in a recliner. He reports a 4 lb weight gain over the last week and increasing fatigue. The client is alert and oriented but is using his accessory muscles to breathe. He reports feeling short of breath, orthopnea, and paroxysmal nocturnal dyspnea. He has bilateral pedal edema (+2), bilateral crackles heard upon auscultation, and jugular vein distention noted on his assessment. The
the client has a medical history of hypertension, coronary artery disease, and a prior myocardial infarction. He was diagnosed with heart failure with reduced ejection fraction (HFrEF) two years ago. Current home medications include lisinopril, metoprolol succinate, furosemide, and atorvastatin.
Which findings suggest a worsening of the client's condition and warrant follow-up by the nurse for a client presenting with shortness of breath and heart failure? Select all that apply.
- A. Describes increasing shortness of breath over the past 2 days
- B. States, 'I feel like I can't catch my breath'
- C. Mentions needing to sleep in a recliner to breathe comfortably
- D. Notes a 4-pound weight gain over the past week
- E. Exhibiting use of accessory muscles during respiration
- F. Auscultation reveals bilateral crackles in the lungs
- G. Reports orthopnea and episodes of paroxysmal nocturnal dyspnea
Correct Answer: A,B,C,D,E,F,G
Rationale: All findings indicate worsening heart failure: A, B, C, G - Shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea suggest pulmonary congestion. D: Weight gain indicates fluid retention. E: Accessory muscle use shows respiratory distress. F: Crackles indicate pulmonary edema.
The nurse is caring for a client who has just been diagnosed with acute pericarditis. Which of the following medications should the nurse anticipate the primary health care provider (PHCP) will prescribe?
- A. isoniazid
- B. colchicine
- C. allopurinol
- D. warfarin
Correct Answer: B
Rationale: Colchicine is used to reduce inflammation in acute pericarditis, often combined with NSAIDs.
The nurse assesses a client three hours following cardiac surgery. Assessment findings were a blood pressure of 88/52 mm Hg, jugular venous distention, and muffled heart sounds. The nurse anticipates that this client will need an immediate
- A. thoracentesis.
- B. pericardiocentesis.
- C. arthrocentesis.
- D. paracentesis.
Correct Answer: B
Rationale: These findings suggest cardiac tamponade, requiring pericardiocentesis to remove fluid compressing the heart.
The following scenario applies to the next 1 items
The nurse in the intensive care unit (ICU) is caring for a 41-year-old male client.
Item 1 of 1
Progress Notes
1544: Received client to ICU immediately following percutaneous transluminal coronary angioplasty followed by stenting via right femoral artery. Notified primary health care provider about client status. Awaiting orders.
The nurse contacts the primary healthcare provider for admission orders
For each potential order, click to specify whether the potential order is indicated or not indicated for the client post-percutaneous transluminal coronary angioplasty.
- A. Head of the bed elevated up to 30 degrees
- B. Elevate the right leg on a pillow
- C. Continuous cardiac monitoring
- D. Serial troponin levels
- E. Keep the client NPO
- F. Obtain serum glucose levels every two hours
Correct Answer: A,C,D,F
Rationale: A: Indicated - Elevating the head of the bed promotes comfort and reduces cardiac workload. B: Not indicated - Elevating the leg is not standard post-angioplasty unless specified for complications. C: Indicated - Continuous monitoring detects arrhythmias post-procedure. D: Indicated - Serial troponin levels monitor for myocardial injury. E: Not indicated - NPO status is typically temporary and not required post-procedure unless specified. F: Indicated - Glucose monitoring is crucial for diabetic patients or those at risk post-procedure.