A 40-year-old patient is admitted with sharp, pleuritic chest pain and dyspnea. The nurse observes jugular venous distension and muffled heart sounds on examination. What is the most appropriate initial nursing action for this patient?

Encouraging the patient to take deep breaths and cough

Administering oxygen to maintain adequate oxygenation

Positioning the patient flat in bed to decrease discomfort

Providing the patient with a warm compress to relieve chest pain

Positive Tinel's sign

Answer and Explanation

The Correct Answer is B

A.   Encouraging the patient to take deep breaths and cough would not address the underlying cause of the symptoms, which may indicate a more serious condition.
B.   Administering oxygen to maintain adequate oxygenation is the most appropriate initial action, as the patient’s symptoms suggest a potentially life-threatening condition like a cardiac tamponade or pulmonary embolism.
C.   Positioning the patient flat in bed is not recommended, as it may exacerbate breathing difficulties and
the patient’s distress.
D.   A warm compress is unlikely to be beneficial in this acute situation and could delay appropriate intervention.

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Correct Answer is A

Explanation

A. Performing weight-bearing exercises, such as walking, jogging, or strength training, helps improve bone density and prevent osteoporosis-related fractures.
B. Caffeine can increase calcium excretion in the urine and may negatively affect bone health, so it is not recommended for clients at risk for osteoporosis.
C. Taking 400 IU of vitamin D per day may be insufficient for clients at risk for osteoporosis. Most guidelines recommend at least 800-1,000 IU of vitamin D daily.
D. Limiting calcium intake to 600 mg per dose is not recommended. Calcium should be taken in doses of 500-600 mg to improve absorption and bone health.

Correct Answer is ["320"]

Explanation

Net fluid balance = Total intake - Total output

Rationale:

Total intake:

IV fluids: 1,000 mL

Antibiotic infusion: 250 mL

Oral intake: 3 cups x 240 mL = 720 mL

Total intake = 1,000 + 250 + 720 = 1,970 mL Total output:

Urine: 1,200 mL

Vomiting: 300 mL Wound drainage: 150 mL

Total output = 1,200 + 300 + 150 = 1,650 mL

Net fluid balance = 1,970 mL - 1,650 mL = +320 mL

The patient has a positive fluid balance of 320 mL.

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A 40-year-old patient is admitted with sharp, pleuritic chest pain and dyspnea. The nurse observes jugular venous distension and muffled heart sounds on examination. What is the most appropriate initial nursing action for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who is at risk for osteoporosis. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

Correct Answer is ["320"]

Explanation

Rationale:

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