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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. "I should use a heating pad when my feet are cold.": Clients with diabetes mellitus may have reduced sensation due to peripheral neuropathy. Using a heating pad increases the risk of burns or injury due to the inability to perceive excessive heat.

B. "I should plan to remain barefoot while I am at home.": Walking barefoot increases the risk of foot injuries, which can lead to infections and complications such as diabetic ulcers. Clients should always wear well-fitting shoes, even at home, to protect their feet.

C. "I should apply lotion between my toes twice a day.": Moisturizing the feet is important to prevent dryness and cracking, but applying lotion between the toes can create excess moisture, increasing the risk of fungal infections.

D. "I should file the edges of my toenails after trimming them.": Filing the edges helps smooth sharp corners, reducing the risk of ingrown toenails and foot injuries, which can be difficult to heal in individuals with diabetes.

A. Hematocrit B. Oxygen saturation C. Activity level D. Blood pressure E. Temperature F. Breath sounds G. Pain level H. Vitamin B12 level

Correct Answer is ["A","B","C","D","H"]

Explanation

Hematocrit: The client's hematocrit level of 24% is significantly low (normal range: 37% to 47%), indicating anemia. This requires follow-up to determine the underlying cause and initiate appropriate treatment, such as iron supplementation or further investigation.
Oxygen saturation: An oxygen saturation level of 94% is slightly low, especially considering the client's reported shortness of breath. Monitoring is necessary to ensure adequate oxygenation and to assess if supplemental oxygen or further respiratory evaluation is needed.
Activity level: The client reports generalized weakness and increased fatigue, particularly becoming short of breath after minimal exertion (e.g., climbing stairs). This decreased activity level is concerning and may indicate cardiovascular or hematological issues, requiring further assessment and follow-up.
Blood pressure: The blood pressure readings indicate orthostatic hypotension, with a drop from 118/60 mm Hg sitting to 102/50 mm Hg standing. This significant drop suggests potential volume depletion or anemia, which requires follow-up to assess fluid status and ensure safety during ambulation.
Vitamin B12 level: The Vitamin B12 level of 159 pg/mL is slightly below the normal range (160 to 950 pg/mL), indicating potential deficiency. This can lead to anemia and neurological issues. Follow-up is needed to evaluate dietary intake and consider supplementation.

Temperature: The client's temperature of 37° C (98.6° F) is within normal limits and does not indicate a need for follow-up. Monitoring for signs of infection or inflammation is important, but this finding is stable.
Breath sounds: The assessment shows clear and present bilateral breath sounds, which indicate no respiratory distress or abnormalities. This finding does not require follow-up.
Pain level: The client reports no pain or discomfort, which is a positive finding and does not necessitate further follow-up. Ongoing assessment for pain should continue, but current findings are stable.

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A nurse is caring for a client who has pericarditis. Which of the following interventions should the nurse implement?

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