A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After Initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Monitor oxygen saturation (SpO2) via continuous pulse oximetry.

Observe neck for jugular vein distention.

Notify healthcare provider to prepare for pericardiocentesis.

Assess for paradoxical blood pressure.

Answer and Explanation

The Correct Answer is C

A. Monitoring oxygen saturation is important but secondary to addressing the immediate cause of the cardiac tamponade.

B. Observing for jugular vein distention is relevant but not the priority compared to directly addressing the tamponade.

C. Notifying the healthcare provider to prepare for pericardiocentesis is the most critical intervention. Cardiac tamponade requires immediate decompression to relieve pressure on the heart and restore normal function.

D. Assessing for paradoxical blood pressure can provide additional information but does not address the immediate need for intervention.

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Correct Answer is B

Explanation

A. It is not necessary to keep the infant home from daycare unless the infant has a fever or other signs of illness.

B. Applying a cool pack to the injection site can help reduce discomfort and swelling.

C. Mild fever after vaccinations is common and not typically serious, but high or persistent fever should be reported.

D. Aspirin should not be given to children due to the risk of Reye's syndrome. Acetaminophen or ibuprofen (for infants older than 6 months) are safer alternatives for reducing fever and discomfort.

A. Substitute natural fruit juices for carbonated drinks. B. Eat high protein foods to achieve ideal body weight. C. Report experiencing right upper quadrant discomfort. D. Use electric heating pad when pain is at its worse.

Correct Answer is A

Explanation

A. Substituting natural fruit juices for carbonated drinks can help reduce the intake of purines and decrease the risk of gout attacks. Carbonated drinks can contribute to dehydration and worsen gout.

B. High protein foods can increase uric acid levels and exacerbate gout, so this is not a recommended dietary practice for managing gout.

C. Reporting right upper quadrant discomfort is important for liver function monitoring but not directly related to the management of gout symptoms.

D. Using an electric heating pad might provide temporary relief but does not address the underlying issue of uric acid levels or dietary management.

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A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After Initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Nursing Test Bank

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A parent brings their 2-month-old infant to the clinic to receive the recommended primary vaccines. Which instruction should the nurse provide the parent about care of the infant after the injections?

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Explanation

The nurse is assessing a client who reports falling 2 days ago and has a history of gouty arthritis that is controlled with allopurinol. The client reports the left knee is swollen and extremely painful to touch. Which instruction should the nurse include in the discharge teaching?

Correct Answer is A

Explanation

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