A nurse is caring for a client who has pericarditis. Which of the following interventions should the nurse implement?

Position the client with the head of the bed elevated to a 15° angle.

Check the client for jugular venous flattening.

Administer an anticoagulant medication to the client.

Assess the client for a paradoxical blood pressure.

Answer and Explanation

The Correct Answer is D

A. Position the client with the head of the bed elevated to a 15° angle: Clients with pericarditis typically experience relief when sitting up and leaning forward, as this reduces pressure on the inflamed pericardium. A 15° elevation is too low to provide significant relief.

B. Check the client for jugular venous flattening: Pericarditis, especially when complicated by cardiac tamponade, leads to jugular venous distension rather than flattening due to impaired venous return to the heart.

C. Administer an anticoagulant medication to the client: Anticoagulants are not routinely used in pericarditis because they may increase the risk of hemorrhagic pericardial effusion, particularly if pericarditis is due to an inflammatory or infectious cause.

D. Assess the client for a paradoxical blood pressure: Pulsus paradoxus, a significant drop in systolic blood pressure during inspiration, is a key sign of cardiac tamponade, a life-threatening complication of pericarditis. Monitoring for this helps in early detection and management.

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Free Nursing Study Resources

Correct Answer is ["A","C","E"]

Explanation

A. Drink 3 L of fluids daily: Increasing fluid intake helps flush bacteria from the urinary tract and dilutes urine, reducing the risk of infection. Adequate hydration also promotes more frequent urination, which prevents bacterial colonization in the bladder.

B. Take a warm bubble bath daily: Bubble baths can introduce irritants and disrupt the normal vaginal flora, increasing the risk of urinary tract infections. Soaking in bathwater containing soap or fragrances can also promote bacterial growth and irritation of the urethra.

C. Drink low-fructose cranberry juice: Cranberry juice contains compounds that help prevent bacteria, particularly Escherichia coli, from adhering to the bladder wall. Low-fructose options are preferred to minimize excessive sugar intake, which can contribute to bacterial growth.

D. Void every 6 hr during the day: Holding urine for long periods allows bacteria to multiply in the bladder, increasing the risk of infection. Voiding every 2 to 4 hours is recommended to promote bladder emptying and reduce bacterial colonization.

E. Wipe the perineal area from front to back after urinating: Wiping from front to back prevents the transfer of bacteria from the anal region to the urethra. This simple hygiene practice helps reduce the risk of E. coli contamination, a leading cause of urinary tract infections.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The first action the nurse should take is assess for dizziness when standing followed by increase dietary iron intake.

Rationale:

Assess for dizziness when standing: The client’s orthostatic hypotension (BP drops from 132/60 to 102/50 mmHg upon standing) and tachycardia (HR 108/min) suggest possible symptomatic anemia. Evaluating for dizziness ensures client safety and helps determine the severity of anemia-related hypoxia.

Increase dietary iron intake: The client has iron deficiency anemia (low hemoglobin, hematocrit, RBC count, and ferritin). Since they follow a vegan diet, increasing plant-based iron sources (e.g., leafy greens, legumes, fortified cereals) and vitamin C intake can improve iron absorption.

Incorrect:

Administer IV fluids: While anemia can cause orthostatic hypotension, fluid resuscitation is not the first-line intervention unless dehydration is present.

Check for signs of bleeding: The client reports no pain or discomfort, and there is no evidence of active bleeding. Anemia is more likely due to chronic dietary deficiency rather than acute blood loss.

Administer vitamin B12 supplements: The client’s vitamin B12 level is slightly low but not critically deficient. The primary issue is iron deficiency, not pernicious anemia.

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A nurse is caring for a client who has pericarditis. Which of the following interventions should the nurse implement?

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Naxlex Comprehensive Predictor Exams

A nurse is teaching about measures to prevent recurring urinary tract infections with a female client. Which of the following information should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

A nurse in a provider's office is caring for a client. Complete the following sentence by using the lists of options. The first action the nurse should take is ____ followed by _____ .

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

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