Nokea
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.
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The nurse has identified a nursing diagnosis of acute pain related to inflammatory process for a patient with acute pericarditis. Which of the following actions is best for the nurse to implement?
- A. Force fluids to 3000 ml to decrease fever and inflammation.
- B. Teach about deep, slow respirations to control the pain.
- C. Remind the patient to ask for the opioid pain medication every 4 hours.
- D. Position the patient in Fowler's position, leaning forward on the overbed table.
Correct Answer: D
Rationale: Sitting upright and leaning forward frequently will decrease the pain associated with pericarditis. Forcing fluids will not decrease the inflammation or pain. Taking deep respirations tends to increase pericardial pain. Opioids are not very effective at controlling pain caused by acute inflammatory conditions and are usually ordered PRN. The patient would receive scheduled doses of a nonsteroidal anti-inflammatory drug (NSAID).
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.
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.
The nurse is assessing a patient with infective endocarditis (IE). Which of the following findings should the nurse expect to assess?
- A. A new regurgitant murmur
- B. A pruritic rash on the trunk
- C. Involuntary muscle movement
- D. Substernal chest pain and pressure
Correct Answer: A
Rationale: New regurgitant murmurs occur in IE because vegetation on the valves prevents valve closure. Substernal chest discomfort, rashes, and involuntary muscle movement are clinical manifestations of other cardiac disorders such as angina and rheumatic fever.
The nurse is planning care for a patient hospitalized with a streptococcal infective endocarditis (IE). Which of the following interventions should the nurse anticipate?
- A. Monitor laboratories for streptococcal antibodies.
- B. Arrange for insertion of a long-term IV catheter.
- C. Encourage the patient to get regular aerobic exercise.
- D. Teach the importance of completing all oral antibiotics.
Correct Answer: B
Rationale: Treatment for IE involves 4-6 weeks of IV antibiotic therapy in order to eradicate the bacteria, which will require a long-term IV catheter such as a peripherally inserted central catheter (PICC) line. Rest periods and limiting physical activity to a moderate level are recommended during the treatment for IE. Oral antibiotics are not effective in eradicating the infective bacteria that cause IE. Blood cultures, rather than antibody levels, are used to monitor the effectiveness of antibiotic therapy.