A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?
Dependent edema
Pericardial friction rub
Paradoxical pulse
Substernal chest pain
The Correct Answer is C
A. Dependent edema can occur with pericarditis but does not indicate an immediate life-threatening complication.
B. A pericardial friction rub is a common finding in pericarditis and helps confirm the diagnosis but is not the priority.
C. A paradoxical pulse (an exaggerated decrease in systolic blood pressure during inspiration) is a sign of cardiac tamponade, a life-threatening complication of pericarditis, and requires immediate intervention.
D. Substernal chest pain is expected with pericarditis and is usually relieved by sitting up and leaning forward, but it is not the most urgent concern.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Instilling erythromycin ophthalmic ointment in the newborn's eyes is important to prevent neonatal conjunctivitis, but drying the newborn takes precedence to prevent heat loss and stimulate breathing immediately after birth.
B. Weighing the newborn and placing identification bracelets can be done after drying the newborn.
C. Placing identification bracelets on the newborn is important for identification purposes but does not take precedence over drying the newborn to prevent heat loss and stimulate breathing.
D. Dry the newborn: Drying the newborn is the priority immediately after birth to prevent heat
loss and stimulate breathing. The newborn is wet from amniotic fluid and may be cold due to the temperature difference between the intrauterine and extrauterine environment. Drying the newborn with a warm, soft towel helps to prevent hypothermia and promotes the initiation of breathing, which is essential for oxygenation and lung expansion. This action supports the
newborn's transition to extrauterine life and sets the stage for subsequent assessments and interventions.
Correct Answer is C
Explanation
A. Varicella-zoster (chickenpox) requires airborne precautions due to its transmission via respiratory droplets or aerosols.
B. Vancomycin-resistant enterococcus (VRE) is typically transmitted through direct contact with contaminated surfaces or equipment and does not require droplet precautions.
C. Pertussis (whooping cough) is transmitted via respiratory droplets and requires droplet precautions to prevent transmission to others.
D. Rotavirus is primarily transmitted through the fecal-oral route and requires contact precautions, not droplet precautions.
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