Nokea
The nurse is caring for a patient with acute pericarditis. What nursing management should be instituted to minimize complications?
- A. The nurse keeps the patient isolated to prevent nosocomial infections.
- B. The nurse encourages coughing and deep breathing.
- C. The nurse helps the patient with activities until the pain and fever subside.
- D. The nurse encourages increased fluid intake until the infection resolves.
Correct Answer: C
Rationale: To minimize complications, the nurse helps the patient with activity restrictions until the pain and fever subside. As the patients condition improves, the nurse encourages gradual increases of activity. Actions to minimize complications of acute pericarditis do not include keeping the patient isolated. Due to pain, coughing and deep breathing are not normally encouraged. An increase in fluid intake is not always necessary.
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A patient with hypertrophic cardiomyopathy (HCM) has been admitted to the medical unit. During the nurses admission interview, the patient states that she takes over-the-counter water pills on a regular basis. How should the nurse best respond to the fact that the patient has been taking diuretics?
- A. Encourage the patient to drink at least 2 liters of fluid daily.
- B. Increase the patients oral sodium intake.
- C. Inform the care provider because diuretics are contraindicated.
- D. Ensure that the patients fluid balance is monitored vigilantly.
Correct Answer: C
Rationale: Diuretics are contraindicated in patients with HCM, so the primary care provider should be made aware. Adjusting the patients sodium or fluid intake or fluid monitoring does not address this important contraindication.
A community health nurse is presenting an educational event and is addressing several health problems, including rheumatic heart disease. What should the nurse describe as the most effective way to prevent rheumatic heart disease?
- A. Recognizing and promptly treating streptococcal infections
- B. Prophylactic use of calcium channel blockers in high-risk populations
- C. Adhering closely to the recommended child immunization schedule
- D. Smoking cessation
Correct Answer: A
Rationale: Group A streptococcus can cause rheumatic heart fever, resulting in rheumatic endocarditis. Being aware of signs and symptoms of streptococcal infections, identifying them quickly, and treating them promptly, are the best preventative techniques for rheumatic endocarditis. Smoking cessation, immunizations, and calcium channel blockers will not prevent rheumatic heart disease.
A patient with mitral valve prolapse is admitted for a scheduled bronchoscopy to investigate recent hemoptysis. The physician has ordered gentamicin to be taken before the procedure. What is the rationale for this?
- A. To prevent bacterial endocarditis
- B. To prevent hospital-acquired pneumonia
- C. To minimize the need for antibiotic use during the procedure
- D. To decrease the need for surgical asepsis
Correct Answer: A
Rationale: Antibiotic prophylaxis is recommended for high-risk patients immediately before and sometimes after the following invasive procedures, such as bronchoscopy. Gentamicin would not be given to prevent pneumonia, to avoid antibiotic use during the procedure, or to decrease the need for surgical asepsis.
The patient has just returned to the floor after balloon valvuloplasty of the aortic valve and the nurse is planning appropriate assessments. The nurse should know that complications following this procedure include what?
- A. Emboli
- B. Mitral valve damage
- C. Ventricular dysrhythmia
- D. Atrial-septal defect
- E. Plaque formation
Correct Answer: A,B,C
Rationale: Possible complications include aortic regurgitation, emboli, ventricular perforation, rupture of the aortic valve annulus, ventricular dysrhythmia, mitral valve damage, and bleeding from the catheter insertion sites. Atrial-septal defect and plaque formation are not complications of a balloon valvuloplasty.
An older adult patient has been diagnosed with aortic regurgitation. What change in blood flow should the nurse expect to see on this patients echocardiogram?
- A. Blood to flow back from the aorta to the left ventricle
- B. Obstruction of blood flow from the left ventricle
- C. Blood to flow back from the left atrium to the left ventricle
- D. Obstruction of blood from the left atrium to left ventricle
Correct Answer: A
Rationale: Aortic regurgitation occurs when the aortic valve does not completely close, and blood flows back to the left ventricle from the aorta during diastole. Aortic regurgitation does not cause obstruction of blood flow from the left ventricle, blood to flow back from the left atrium to the left ventricle, or obstruction of blood from the left atrium to left ventricle.