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The nurse is conducting postoperative teaching with a patient who had a mitral valve replacement with a mechanical valve. Which of the following information should the nurse include in the teaching plan?
- A. Use of daily Aspirin for anticoagulation
- B. Correct method for taking the radial pulse
- C. Need for frequent laboratory blood testing
- D. Possibility of valve replacement in 7-10 years
Correct Answer: C
Rationale: Anticoagulation therapy with warfarin is needed for a patient with mechanical valves to prevent clotting on the valve; this will require frequent international normalized ratio (INR) testing. Daily Aspirin use will not be effective in reducing risk for clots on the valve. Mechanical valves are durable and would last longer than 7-10 years. Monitoring of the radial pulse is not necessary after valve replacement.
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The nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with infective endocarditis (IE). Which of the following findings support this diagnosis?
- A. Fever, chills, and diaphoresis
- B. Urine output less than 30 ml/hour
- C. Petechiae of the buccal mucosa and conjunctiva
- D. Increase in pulse rate of 15 beats/minute with activity
Correct Answer: B
Rationale: Decreased renal perfusion caused by inadequate cardiac output will lead to poor urine output. Petechiae, fever, chills, and diaphoresis are symptoms of IE but are not caused by decreased cardiac output. An increase in pulse rate of 15 beats/minute is normal with exercise.
The nurse is caring for a patient who has had recent cardiac surgery and develops pericarditis, with symptoms of chest pain at a level 6 (0-10 scale) with deep breathing. Which of the following prescribed PRN medications should the nurse administer?
- A. Fentanyl 2 mg IV
- B. Morphine sulphate 6 mg IV
- C. Ibuprofen 800 mg PO
- D. Acetaminophen 650 mg PO
Correct Answer: C
Rationale: The pain associated with pericarditis is caused by inflammation, so nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen are most effective. Opioid analgesics are usually not used for the pain associated with pericarditis.
The nurse is caring for a patient who had an acute myocardial infarction (MI) 3 days prior and has symptoms of stabbing chest pain that increases with deep breathing. Which of the following actions should the nurse take first?
- A. Auscultate the heart sounds.
- B. Check the patient's oral temperature.
- C. Notify the patient's health care provider.
- D. Give the ordered acetaminophen.
Correct Answer: A
Rationale: The patient's clinical manifestations and history are consistent with pericarditis, and the first action by the nurse should be to listen for a pericardial friction rub. Checking the temperature, giving acetaminophen, and notifying the health care provider also are appropriate actions but would not be done before listening for a rub.
Which of the following techniques should the nurse use to assess the patient with pericarditis for the presence of a pericardial friction rub?
- A. Auscultate with the stethoscope diaphragm at the lower left sternal border.
- B. Listen for a rumbling, low-pitched, systolic sound over the left anterior chest.
- C. Feel the precordial area with the palm of the hand to detect vibration with cardiac contraction.
- D. Ask the patient to stop breathing during auscultation to distinguish the sound from a pleural friction rub.
Correct Answer: A
Rationale: Pericardial friction rubs are heard best with the diaphragm at the lower left sternal border. Because dyspnea is one clinical manifestation of pericarditis, the nurse should time the friction rub with the pulse rather than ask the patient to stop breathing during auscultation. Friction rubs are not typically low pitched or rumbling and are not confined to systole. Rubs are not assessed by palpation.
The nurse establishes the nursing diagnosis of ineffective health maintenance related to lack of knowledge concerning long-term management of rheumatic fever when a patient who is recovering from rheumatic fever says which of the following statements?
- A. I will need to have monthly antibiotic injections for 10 years or longer.
- B. I will need to take Aspirin or ibuprofen to relieve my joint pain.
- C. I will call the doctor if I develop excessive fatigue or difficulty breathing.
- D. I will be immune to further episodes of rheumatic fever after this infection.
Correct Answer: D
Rationale: Patients with a history of rheumatic fever are more susceptible to a second episode. The other patient statements are correct and would not support the nursing diagnosis of ineffective health maintenance.