A nurse is caring for a client who has pericarditis. Which of the following interventions should the nurse implement?
Position the client with the head of the bed elevated to a 15° angle.
Check the client for jugular venous flattening.
Administer an anticoagulant medication to the client.
Assess the client for a paradoxical blood pressure.
The Correct Answer is D
A. Position the client with the head of the bed elevated to a 15° angle: Clients with pericarditis typically experience relief when sitting up and leaning forward, as this reduces pressure on the inflamed pericardium. A 15° elevation is too low to provide significant relief.
B. Check the client for jugular venous flattening: Pericarditis, especially when complicated by cardiac tamponade, leads to jugular venous distension rather than flattening due to impaired venous return to the heart.
C. Administer an anticoagulant medication to the client: Anticoagulants are not routinely used in pericarditis because they may increase the risk of hemorrhagic pericardial effusion, particularly if pericarditis is due to an inflammatory or infectious cause.
D. Assess the client for a paradoxical blood pressure: Pulsus paradoxus, a significant drop in systolic blood pressure during inspiration, is a key sign of cardiac tamponade, a life-threatening complication of pericarditis. Monitoring for this helps in early detection and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Inspect the mouth once each week for sores: Frequent oral assessments are necessary, especially after a partial glossectomy, to monitor for infection, healing complications, or signs of malignancy recurrence. Checking only once per week is insufficient for early detection of issues.
B. Use text or pictures to communicate needs postoperatively: A partial glossectomy can impair speech, making communication difficult. Using alternative methods such as writing, text, or pictures helps ensure effective communication, especially in the immediate postoperative period.
C. Rinse with an alcohol-based mouthwash instead of brushing: Alcohol-based mouthwashes can cause irritation and delay healing. Instead, gentle oral hygiene with a soft toothbrush and non-alcoholic rinses like saline or chlorhexidine is recommended to maintain cleanliness without irritation.
D. Increase intake of dense, high-fiber foods: Soft, easy-to-swallow foods are preferred after a partial glossectomy to prevent irritation and facilitate healing. Dense, high-fiber foods can be difficult to chew and may cause discomfort, increasing the risk of aspiration or delayed wound healing.
Correct Answer is A
Explanation
A. Initiate oxygen therapy: Sepsis can lead to tissue hypoxia and organ dysfunction due to impaired perfusion. Oxygen therapy is the priority to ensure adequate oxygenation, prevent respiratory failure, and support vital organ function.
B. Administer antibiotics: Broad-spectrum antibiotics are essential to treat the underlying infection, but they should be given after obtaining blood cultures to ensure accurate pathogen identification and prevent delays in appropriate therapy.
C. Obtain blood cultures: Blood cultures must be collected before antibiotic administration to identify the causative organism, but stabilizing the client's oxygenation and perfusion takes precedence in acute management.
D. Begin an IV crystalloid infusion: Fluid resuscitation is crucial for managing septic shock, but oxygen therapy should be initiated first to immediately improve oxygen delivery and prevent hypoxia-related complications.
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