Nokea
Which nursing diagnosis would be priority for the client diagnosed with myocarditis?
- A. Anxiety related to possible long-term complications.
- B. High risk for injury related to antibiotic therapy.
- C. Increased cardiac output related to valve regurgitation.
- D. Activity intolerance related to impaired cardiac muscle function.
Correct Answer: D
Rationale: Myocarditis impairs cardiac function, making activity intolerance (D) the priority due to reduced cardiac output. Anxiety (A), injury (B), and increased output (C) are less immediate or incorrect.
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Which signs/symptoms should the nurse assess in any client who has a long-term valvular heart disease? Select all that apply.
- A. Paroxysmal nocturnal dyspnea.
- B. Orthopnea.
- C. Cough.
- D. Pericardial friction rub.
- E. Pulsus paradoxus.
Correct Answer: A,B,C
Rationale: Valvular disease causes fluid overload, leading to PND (A), orthopnea (B), and cough (C). Pericardial rub (D) and pulsus paradoxus (E) are specific to pericarditis/tamponade.
The nurse is assessing the client diagnosed with congestive heart failure. Which laboratory data would indicate that the client is in severe congestive heart failure?
- A. An elevated B-type natriuretic peptide (BNP).
- B. An elevated creatine kinase (CK-MB).
- C. A positive D-dimer.
- D. A positive ventilation/perfusion (V/Q) scan.
Correct Answer: A
Rationale: Elevated BNP (A) is specific to heart failure, reflecting ventricular stress. CK-MB (B) indicates myocardial infarction, D-dimer (C) suggests clotting, and V/Q scan (D) is for pulmonary embolism.
The client is diagnosed with pericarditis. When assessing the client, the nurse is unable to auscultate a friction rub. Which action should the nurse implement?
- A. Notify the health-care provider.
- B. Document that the pericarditis has resolved.
- C. Ask the client to lean forward and listen again.
- D. Prepare to insert a unilateral chest tube.
Correct Answer: C
Rationale: Leaning forward (C) enhances auscultation of a pericardial friction rub, which may be positional. Notifying HCP (A), documenting resolution (B), or chest tube (D) are premature or unrelated.
The nurse is administering morning medications to clients on a telemetry unit. Which medication would the nurse question?
- A. Furosemide IVP to a client with a potassium level of 3.6 mEq/L.
- B. Digoxin orally to a client diagnosed with rapid atrial fibrillation.
- C. Enalapril orally to a client whose BP is 86/64 and apical pulse is 65.
- D. Morphine IVP to a client complaining of chest pain and who is diaphoretic.
Correct Answer: C
Rationale: Enalapril (C) is contraindicated with hypotension (BP 86/64), risking further BP drop. Furosemide with K+ 3.6 (A), digoxin for AF (B), and morphine for chest pain (D) are appropriate.
The client has just returned from a cardiac catheterization. Which assessment data would warrant immediate intervention from the nurse?
- A. The client's BP is 110/70 and pulse is 90.
- B. The client's groin dressing is dry and intact.
- C. The client refuses to keep the leg straight.
- D. The client denies any numbness and tingling.
Correct Answer: C
Rationale: Refusing to keep the leg straight (C) risks bleeding from the femoral site, requiring immediate intervention. Normal BP/pulse (A), intact dressing (B), and no numbness (D) are expected.