What is the most important nursing action in caring for a patient who has just recovered from rheumatic fever?

Educate the patient on the necessity of continuous antibiotic prophylaxis.

Inform the patient about the importance of ongoing anticoagulation.

Instruct the patient on the need to adhere to standard infection control procedures.

Guide the patient on how to manage their physical activity.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Education on the necessity of continuous antibiotic prophylaxis is crucial for patients who have just recovered from rheumatic fever. Rheumatic fever is an inflammatory disease that can develop as a complication of untreated or inadequately treated strep throat or scarlet fever.
Patients who have had rheumatic fever are at risk of getting it again if they have another strep infection. Continuous antibiotic prophylaxis can prevent recurrent infections and the development of rheumatic heart disease.
Choice B rationale
While anticoagulation therapy may be necessary for some patients with heart conditions, it is not typically the most important nursing action for a patient who has just recovered from rheumatic fever. Rheumatic fever can cause inflammation and damage to the heart valves, but it does not typically cause blood clots, which are the primary reason for anticoagulation therapy.
Choice C rationale
Adherence to standard infection control procedures is important for all patients, but it is not the most important nursing action for a patient who has just recovered from rheumatic fever. The primary concern for these patients is preventing recurrent strep infections, which can be achieved through continuous antibiotic prophylaxis.
Choice D rationale
While physical activity management may be part of the overall care plan for a patient who has just recovered from rheumatic fever, it is not typically the most important nursing action. The primary concern for these patients is preventing recurrent strep infections, which can be achieved through continuous antibiotic prophylaxis.

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Correct Answer is C

Explanation

The patient with a blood pressure of 116/42 mm Hg has a mean arterial pressure (MAP) of approximately 67 mm Hg, which is less than the standard policy of 70 mm Hg. This could indicate inadequate blood flow to the vital organs, necessitating notification of the healthcare provider.

A. Sexual activity uses about as much energy as climbing two flights of stairs. B. Holding and cuddling are good ways to maintain intimacy after a heart attack. C. The doctor will provide sexual guidelines when your heart is strong enough. D. Most patients are able to enjoy intercourse without any complications.

Correct Answer is A

Explanation

Choice A rationale
Sexual activity uses about as much energy as climbing two flights of stairs. This comparison can help patients understand that if they can perform activities of similar exertion without chest pain or undue fatigue, it may be safe to resume sexual activity. However, patients should always consult with their healthcare provider before resuming sexual activity after an acute myocardial infarction (AMI).
Choice B rationale
While holding and cuddling are good ways to maintain intimacy after a heart attack, this does not directly address the patient’s question about safely resuming sexual intercourse.
Choice C rationale
While it is true that the doctor will provide sexual guidelines when the patient’s heart is strong enough, this response does not provide the patient with immediate guidance or reassurance.
Choice D rationale
While most patients are able to enjoy intercourse without any complications, this statement may be too general and does not take into account the individual patient’s health status and recovery progress.

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What is the most important nursing action in caring for a patient who has just recovered from rheumatic fever?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The standard policy on the cardiac unit states, “Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg.”. Which patient should the nurse call the health care provider about?

Correct Answer is C

Explanation

For a patient recovering from an acute myocardial infarction (AMI) who inquires about safely resuming sexual intercourse, what would be the best response from the nurse?

Correct Answer is A

Explanation

A nurse is providing care for a patient who has weak pedal pulses, no hair on both legs, and a full-thickness wound on the right lateral malleolus with defined margins, which includes a small amount of serous exudate. Which intervention should not be performed?

Which patient statement would help the nurse confirm a previous diagnosis of chronic stable angina?

A nurse is caring for a client on a cardiac monitor. The patient’s heart monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. What is the first action the nurse should take?

A nurse is preparing a client for a scheduled Percutaneous Coronary Intervention (PCI). Which statement made by the client should the nurse report to the Primary Healthcare Provider (PHCP)?

A nurse is caring for a client who has developed cardiac tamponade. Which of the following symptoms should the nurse expect to observe?

Given the electrocardiogram tracing below for a client who is unresponsive and without a pulse, what should be the nurse’s priority action?

When assessing a male patient in the telemetry unit who is experiencing persistent, crushing chest pain, which symptoms would lead the nurse to suspect a myocardial infarction?

The nurse is caring for a client with weak pedal pulses, absent hair on bilateral legs, and a full-thickness wound on the right lateral malleolus with defined margins, including a minimal amount of serous exudate. Which of the following interventions is contraindicated?