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The nurse is caring for a client who has developed cardiac tamponade. Which of the following prescriptions should the nurse clarify with the primary healthcare provider (PHCP)?
- A. Positive pressure ventilation
- B. Pericardiocentesis
- C. Echocardiography
- D. 0.9% saline bolus
Correct Answer: A
Rationale: Positive pressure ventilation can worsen cardiac tamponade by further compressing the heart, so it should be clarified.
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The nurse is caring for a client newly admitted with infective endocarditis (IE). The nurse should plan for which intervention in the client's care plan?
- A. initiating contact and droplet precautions
- B. obtain a prescription for intravenous antivirals
- C. obtain a prescription for enoxaparin
- D. monitor renal function
Correct Answer: D
Rationale: Infective endocarditis can cause glomerulonephritis, necessitating renal function monitoring (e.g., creatinine levels).
The nurse is caring for a client with the below tracing on the electrocardiogram. The nurse should expect the client to demonstrate which clinical manifestation in conjunction with this electrocardiogram tracing? See the exhibit.
- A. Jugular venous distention (JVD)
- B. Systolic murmur
- C. Irregular pulse
- D. Widened pulse pressure
Correct Answer: C
Rationale: An irregular ECG tracing, such as in atrial fibrillation, typically correlates with an irregular pulse due to inconsistent ventricular contractions.
The nurse is caring for a client who has been ordered a sodium-restricted diet following a myocardial infarction. Which of the following meals would be most appropriate to suggest?
- A. Turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange.
- B. Broiled fish, 1 baked potato, 1/2 cup canned beets, 1 orange, and milk.
- C. Canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple.
- D. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice.
Correct Answer: A
Rationale: Fresh foods like turkey, sweet potato, and green beans are low in sodium, unlike canned or processed foods.
The following scenario applies to the next 1 items
The nurse in the intensive care unit (ICU) is caring for 58-year-old male client
Item 1 of 1
Medical History Vital Signs Medication Administration Record
• atrial fibrillation
• chronic obstructive pulmonary disease
• hyperlipidemia
• chronic back pain
Based on the 2000 vital signs, select two (2) immediate actions the nurse should take for a client with atrial fibrillation, COPD, hyperlipidemia, and chronic back pain.
- A. Stop the diltiazem infusion
- B. Apply supplemental oxygen via nonrebreather face mask
- C. Stop the 0.9% saline infusion
- D. Notify the primary healthcare provider
- E. Assess the client for back pain
- F. Request a prescription to change the intravenous fluids to hypertonic saline
Correct Answer: B,D
Rationale: Supplemental oxygen addresses potential hypoxia from COPD or atrial fibrillation complications. D: Correct - Notifying the provider ensures timely management of abnormal vital signs. A, C, E, F: Incorrect - No vital sign data suggests stopping infusions, assessing back pain, or changing to hypertonic saline.
The nurse is caring for a client with congestive heart failure experiencing an exacerbation. Which of the following of the client's vital signs would indicate that the client is experiencing a complication?
- A. Decrease in blood pressure
- B. Increase in temperature
- C. Decrease in respiratory rate
- D. Increase in blood pressure
Correct Answer: A
Rationale: A decrease in blood pressure during a CHF exacerbation may indicate cardiogenic shock, a serious complication.