A nurse is admitting a client who has a history of atrial fibrillation. Which of the following conditions should the nurse recognize atrial fibrillation places the client at risk for?
Hemothorax
Cardiac tamponade
Pulmonary emboli
Widened pulse pressure
The Correct Answer is C
Rationale:
A. Hemothorax: Hemothorax is accumulation of blood in the pleural space, typically caused by trauma, surgery, or ruptured vessels. Atrial fibrillation does not directly increase the risk of hemothorax.
B. Cardiac tamponade: Cardiac tamponade occurs when fluid accumulates in the pericardial sac, impairing cardiac output. This condition is usually associated with trauma, pericarditis, or post-surgical complications, not atrial fibrillation.
C. Pulmonary emboli: Atrial fibrillation can lead to stasis of blood in the atria, especially the left atrial appendage, increasing the risk of thrombus formation. If a clot dislodges and travels to the lungs, it can cause a pulmonary embolism, making this a serious complication to monitor for.
D. Widened pulse pressure: Widened pulse pressure reflects the difference between systolic and diastolic blood pressure and is associated with conditions like aortic regurgitation. It is not a direct consequence of atrial fibrillation and is not considered a primary risk in these clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Reassure the client that their injuries are not life threatening: While reassurance may seem supportive, minimizing the client’s experience or focusing on injury severity too early may invalidate their emotional trauma and hinder trust-building.
B. Limit the number of staff members providing care for the client: Limiting staff exposure promotes a sense of safety and control for the client, who may feel vulnerable and traumatized. Consistency in caregivers helps reduce anxiety and supports trauma-informed care principles by minimizing re-traumatization and promoting trust.
C. Ask the client for details about the assault: The nurse should not probe for specific details because repeated questioning can intensify trauma and emotional distress. Instead, the nurse should allow the client to share voluntarily when ready and defer detailed questioning to a trained sexual assault nurse examiner (SANE).
D. Instruct the client to shower and change their clothes: The client should not bathe, change, or wash clothing before evidence collection. The nurse should explain the importance of preserving evidence and provide clean clothing after the forensic examination is complete.
Correct Answer is B
Explanation
Rationale:
A. Insert a rectal suppository: While a suppository can relieve constipation, abdominal distention after laparoscopic surgery is often caused by retained gas from insufflation rather than stool, so this intervention may not be effective.
B. Assist the client to ambulate: Early ambulation promotes peristalsis and helps the body expel retained carbon dioxide gas from the abdomen, which is a common cause of post-laparoscopic distention. This is a safe and effective first-line intervention.
C. Prepare the client for a paracentesis: Paracentesis is used to remove fluid in cases of ascites, not routine post-surgical gas-related distention. It is unnecessary for uncomplicated laparoscopic procedures.
D. Place the client in the prone position: While repositioning may offer some comfort, it does not significantly facilitate the expulsion of gas or reduce abdominal distention. Ambulation is more effective.
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