A patient recovering from a myocardial infarction (MI) develops cheat pain on day 3 that increases when taking a deep breath, lying flat, and is relieved by leaning forward. Which additional assessment data should the nurse collect next?

Auscultate for a pericardial friction rub

Inspect the skin for petechia

Palpate the radial pulses bilaterally

Assess for abdominal pain

Answer and Explanation

The Correct Answer is A

A. Auscultate for a pericardial friction rub: These symptoms are classic for pericarditis, a complication of MI. A pericardial friction rub is a key diagnostic finding.

B. Inspect the skin for petechiae: Petechiae are associated with conditions like infective endocarditis or thrombocytopenia, not pericarditis.

C. Palpate the radial pulses bilaterally: Assessing radial pulses is essential for circulation but does not directly relate to pericarditis symptoms.

D. Assess for abdominal pain: Abdominal pain is not typical of pericarditis and would not be the priority assessment.

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Correct Answer is A

Explanation

A. 3% hypertonic saline: In SIADH, the body holds onto too much water, leading to dilutional hyponatremia. Hypertonic saline helps to slowly raise the sodium level and correct the dilution.

B. Normal saline solution: Normal saline (0.9%) would not be effective for SIADH as it is isotonic and would not correct the sodium imbalance.

C. Dextrose 5% in water: This would not be appropriate, as it contains free water and could exacerbate hyponatremia in a client with SIADH.

D. Lactated Ringers: This is an isotonic solution and would not effectively address the dilutional hyponatremia caused by SIADH.

A. Facilitates the insertion of a pacemaker B. Assesses the function of the SA node C. Evaluates the effectiveness of prescribed antiarrhythmic medication D. Identifies the location of abnormal sites within cardiac muscle E. Treats certain arrhythmias through the process of ablation

Correct Answer is ["B","C","D","E"]

Explanation

A. Facilitates the insertion of a pacemaker: This is not the purpose of an electrophysiology study (EPS). A pacemaker may be considered based on the results, but EPS itself does not insert the device.

B. Assesses the function of the SA node: EPS is used to assess the electrical activity of the heart, including the function of the SA node.

C. Evaluates the effectiveness of prescribed antiarrhythmic medication: EPS can help evaluate how well antiarrhythmic medications are controlling arrhythmias.

D. Identifies the location of abnormal sites within cardiac muscle: EPS is often used to locate areas of the heart responsible for abnormal electrical conduction and arrhythmias.

E. Treats certain arrhythmias through the process of ablation: One of the therapeutic purposes of EPS is to perform ablation, which can treat certain arrhythmias by destroying abnormal tissue.

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A patient recovering from a myocardial infarction (MI) develops cheat pain on day 3 that increases when taking a deep breath, lying flat, and is relieved by leaning forward. Which additional assessment data should the nurse collect next?

Nursing Test Bank

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