Which action by the nurse will determine if therapies ordered for a patient with chronic constrictive pericarditis are effective?
Check the electrocardiogram (ECG) for ST segment changes.
Assess for the presence of jugular venous distention (VD).
Monitor for changes in the patient's sedimentation rate.
Assess for the presence of a paradoxical pulse.
The Correct Answer is B
Choice A rationale:
ST segment changes on an ECG are not typically associated with chronic constrictive pericarditis.
Choice B rationale:
Jugular venous distention (JVD) is a common sign of chronic constrictive pericarditis. If JVD is not present, it may indicate that the therapies are effective.
Choice C rationale:
While the sedimentation rate can indicate inflammation, it is not specific to chronic constrictive pericarditis.
Choice D rationale:
The presence of a paradoxical pulse is not typically associated with chronic constrictive pericarditis.
So, the correct answer is B, after analyzing all choices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A weight increase from 120 pounds to 122 pounds over 3 days is within the normal fluctuation range.
Choice B rationale:
A serum potassium level of 3.0 mEq/L after 1 week of therapy is concerning because it’s below the normal range (3.5-5.0 mEq/L)171819. This could indicate hypokalemia, which can cause serious complications if left untreated.
Choice C rationale:
A palpable liver edge 2 cm below the ribs on the right side could suggest an abnormality such as an enlarged liver.
Choice D rationale:
The presence of 1+ to 2+ edema in the feet and ankles could indicate conditions like heart failure or venous insufficiency.
So, the correct answer is Choice B, after analyzing all choices.
Correct Answer is A
Explanation
Choice A rationale:
Elevated troponin is a sign of heart damage, which could be caused by a heart attack or other stresses on the heart. This is a critical finding that needs immediate attention.
Choice B rationale:
Q waves on an ECG can indicate a previous heart attack or myocardial infarction. However, they can also be a normal variant, meaning they are a harmless variation in the electrical activity of the heart.
Choice C rationale:
Bilateral crackles in the lungs can indicate mucus or fluid in the base of the lungs, often associated with conditions like pneumonia, heart failure, or bronchitis.
Choice D rationale:
Hyperglycemia, or high blood glucose, can be a sign of diabetes. If untreated, it can lead to serious complications like ketoacidosis.
So, the correct answer is Choice A, after analyzing all choices.
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