Nokea
The nurse is caring for a client who has acute pericarditis. Which of the following findings would be a priority to follow up?
- A. chest pain that is worse with deep inspiration
- B. muffled heart tones and jugular venous distension
- C. pericardial friction rub auscultated at the left sternal border
- D. temperature of 100.7 F (38.2 C) and a nonproductive cough
Correct Answer: B
Rationale: Muffled heart tones and jugular venous distension (B) suggest pericardial effusion or tamponade, a life-threatening complication requiring urgent follow-up. Chest pain (A) and friction rub (C) are expected, and mild fever (D) is less urgent.
You may also like to solve these questions
A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts on death and dying at this age?
- A. Death is personified as the bogeyman or devil
- B. Death is perceived as being irreversible
- C. The child feels guilty for the grandmother's death
- D. The child is worried that he, too, might die
Correct Answer: A
Rationale: Death is personified as the bogeyman or devil. Personification of death is typical of this developmental level.
When using an interpreter to teach a client about a procedure to do in the home, the nurse should take which approach?
- A. Speak directly to the interpreter while presenting information and use pauses for questions
- B. Talk to the interpreter in advance and leave the client and interpreter alone
- C. Include a family member and direct communications to that person
- D. Face the client while presenting the information as the interpreter talks in the native language
Correct Answer: D
Rationale: Face the client while presenting the information as the interpreter talks in the native language. This allows non-verbal communication and maintains a client-focused approach.
A client is admitted with infective endocarditis (IE). Which finding would alert the nurse to a complication of this condition?
- A. dyspnea
- B. heart murmur
- C. macular rash
- D. Hemorrhage
Correct Answer: B
Rationale: Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off, causing emboli and leaving ulcerations on the valve leaflets. These emboli produce findings of cardiac murmur, fever, anorexia, malaise and neurologic sequelae of emboli.
The nurse is caring for an infant who has a prescription for amoxicillin 25 mg/kg/day in 2 divided doses. The client weighs 16.5 lb (7.5 kg). The nurse has amoxicillin oral suspension 125 mg/5 mL available. How many mL should the nurse administer to the client with each dose? Record your answer using 2 decimal places.
Correct Answer: 3.75 mL/dose
Rationale: Calculation: 7.5 kg × 25 mg/kg/day = 187.5 mg/day. Divided into 2 doses = 93.75 mg/dose. 125 mg/5 mL = 25 mg/mL. 93.75 mg ÷ 25 mg/mL = 3.75 mL/dose (A).
A 24-year-old female client is prescribed isotretinoin for severe cystic acne. Which instruction is most important for the nurse to reinforce?
- A. Apply lubricating eye drops when wearing contacts
- B. Do not break, crush, or chew capsules
- C. Use sunscreen routinely during therapy
- D. Use two forms of contraception consistently
Correct Answer: D
Rationale: Isotretinoin is highly teratogenic, so using two forms of contraception (D) is critical to prevent pregnancy. Sunscreen (C) is important for photosensitivity, but contraception is the priority.