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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.
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The following scenario applies to the next 1 items
The nurse cares for a client admitted for a myocardial infarction
Item 1 of 1
Nurses' Note
0800 - Client was found in bed pale and diaphoretic, stating, I do not feel well. Approximately two minutes later, the cardiac monitor showed ventricular tachycardia. Upon assessment, the client became unresponsive and did not have a pulse.
For each potential intervention, click to specify if it is essential or contraindicated: A. Call a code blue, B. Cardiovert the client, C. Defibrillate the client, D. Anticipate a prescription for intravenous digoxin, E. Perform chest compressions
- A. Call a code blue
- B. Cardiovert the client
- C. Defibrillate the client
- D. Anticipate a prescription for intravenous digoxin
- E. Perform chest compressions
Correct Answer: A,C,E
Rationale: A: Essential - Calling a code blue activates the emergency response team for immediate intervention. B: Contraindicated - Cardioversion is used for synchronized shocks in stable rhythms like atrial fibrillation, not for pulseless ventricular tachycardia. C: Essential - Defibrillation is the treatment for pulseless ventricular tachycardia to restore a viable rhythm. D: Contraindicated - Digoxin is not used in acute cardiac arrest; it is for heart failure or rate control in arrhythmias. E: Essential - Chest compressions are required in pulseless clients as part of CPR.
The nurse cares for a client with the below tracing on the electrocardiogram. The client is unresponsive and without a pulse. The nurse should implement which priority treatment based on the tracing
- A. Start cardiopulmonary resuscitation (CPR)
- B. Perform immediate defibrillation
- C. Initiate intravenous (IV) access
- D. Review the client's most recent electrolyte levels
Correct Answer: B
Rationale: Pulseless ventricular fibrillation or tachycardia requires immediate defibrillation to restore rhythm.
Which of the following heart sounds would the nurse expect to auscultate in a client with systolic heart failure? Select all that apply.
- A. S1
- B. S2
- C. S3
- D. S4
- E. Pleural friction rub
Correct Answer: C
Rationale: S1 is a normal heart sound. B: Incorrect - S2 is a normal heart sound. C: Correct - S3 is associated with systolic heart failure due to rapid ventricular filling. D: Incorrect - S4 is linked to diastolic dysfunction, not systolic failure. E: Incorrect - Pleural friction rub indicates pleural inflammation, not heart failure.
The nurse is caring for a client with atrial fibrillation. Which of the following client findings requires immediate follow-up by the nurse?
- A. Irregular QRS complexes on telemetry reading
- B. Irregular peripheral pulse
- C. Reports of intermittent palpitations
- D. Blurred vision
Correct Answer: D
Rationale: Blurred vision may indicate a stroke, a serious complication of atrial fibrillation due to thromboembolism.
Which of the following findings would the nurse expect to observe in a client with peripheral arterial disease (PAD)? Select all that apply.
- A. Decreased peripheral pulses
- B. Pain with ambulation
- C. Reddish-brown ankle discoloration
- D. Bilateral dependent edema
- E. Protruding veins in the leg
Correct Answer: A,B,C
Rationale: Decreased pulses result from arterial obstruction. Pain with ambulation (claudication) is a hallmark of PAD. C: Correct - Reddish-brown discoloration indicates chronic arterial insufficiency. D: Incorrect - Edema is more typical of venous issues. E: Incorrect - Protruding veins suggest venous disease, not arterial.