Nokea
The nurse is conducting discharge teaching about the need for prophylactic antibiotics when having dental procedures. This teaching would be provided to a patient with which of the following diagnoses?
- A. Acute myocardial infarction
- B. Exacerbation of heart failure
- C. Mechanical mitral valve replacement
- D. Rheumatic fever after a streptococcal infection
Correct Answer: C
Rationale: Current guidelines recommend the use of prophylactic antibiotics before dental procedures for patients with prosthetic valves to prevent infective endocarditis (IE). The other patients are not at risk for IE.
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Cardiac tamponade is suspected in a patient who has acute pericarditis. Which of the following actions should the nurse implement to assess for the presence of pulsus paradoxus?
- A. Check the electrocardiogram (ECG) for variations in rate in relation to inspiration and expiration
- B. Note when Korotkoff sounds are audible during both inspiration and expiration.
- C. Auscultate for a pericardial friction rub that increases in volume during inspiration.
- D. Subtract the diastolic blood pressure (DBP) from the systolic blood pressure (SBP).
Correct Answer: B
Rationale: Pulsus paradoxus exists when there is a gap of greater than 10 mm Hg between when Korotkoff sounds can be heard during only expiration and when they can be heard throughout the respiratory cycle. The other methods described would not be useful in determining the presence of pulsus paradoxus.
Which of the following assessment information obtained by the nurse for a patient with aortic stenosis is most important to report to the health care provider?
- A. The patient complains of chest pain associated with ambulation.
- B. A loud systolic murmur is audible along the right sternal border.
- C. A thrill is palpable at the 2nd intercostal space, right sternal border.
- D. The point of maximum impulse (PMI) is at the left midclavicular line.
Correct Answer: A
Rationale: Chest pain occurring with aortic stenosis is caused by cardiac ischemia, and reporting this information would be a priority. A systolic murmur and thrill are expected in a patient with aortic stenosis. A PMI at the left midclavicular line is normal.
The nurse is assessing a patient who has mitral valve regurgitation. Which of the following findings should be communicated to the health care provider immediately?
- A. 4+ peripheral edema in both legs
- B. Crackles audible to the lung apices
- C. A palpable thrill felt over the left anterior chest
- D. A loud systolic murmur all across the precordium
Correct Answer: B
Rationale: Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure with pulmonary congestion and needs immediate interventions such as diuretics. A systolic murmur and palpable thrill would be expected in a patient with mitral regurgitation. Although 4+ peripheral edema indicates a need for a change in therapy, it does not need to be addressed urgently.
Which of the following assessment data obtained by the nurse when assessing a patient with acute pericarditis should be reported immediately to the health care provider?
- A. Pulsus paradoxus 8 mm Hg
- B. Blood pressure (BP) of 166/90
- C. Jugular vein distension (JVD) to the level of the jaw
- D. Level 6 (0-10 scale) chest pain with deep inspiration
Correct Answer: C
Rationale: The JVD indicates that the patient may have developed cardiac tamponade and may need rapid intervention to maintain adequate cardiac output. Hypertension would not be associated with complications of pericarditis, and the BP is not high enough to indicate that there is any immediate need to call the health care provider. A pulsus paradoxus of 8 mm Hg is normal. Level 6/10 chest pain should be treated but is not unusual with pericarditis.
The nurse is caring for a patient with rheumatic fever who has subcutaneous nodules, erythema marginatum, and polyarthritis. Which of the following nursing diagnoses best reflects these findings?
- A. Activity intolerance related to physical deconditioning (arthralgia)
- B. Risk for infection as evidenced by immunosuppression
- C. Chronic pain related to injury agent (permanent joint fixation)
- D. Risk for impaired skin integrity evidenced by pressure over bony prominence
Correct Answer: A
Rationale: The patient's joint pain will lead to difficulty with activity. The skin lesions seen in rheumatic fever are not open or pruritic and thus do not pose a high risk for infection. Although acute joint pain will be a problem for this patient, joint inflammation is a temporary clinical manifestation of rheumatic fever and is not associated with permanent joint changes.