A patient has pain due to acute pericarditis. Which action would the nurse take?.
Teach the patient to take deep, slow breaths to control the pain.
Place the patient in Fowler's position, leaning forward on the table.
Force fluids to 3000 mL/day to decrease the inflammation.
Provide a fresh ice bag every hour for the patient to place on the chest.
The Correct Answer is B
Choice A rationale:
Teaching the patient to take deep, slow breaths might not be effective in controlling the pain due to acute pericarditis.
Choice B rationale:
Placing the patient in Fowler’s position, leaning forward on the table, can help relieve the pain associated with acute pericarditis.
Choice C rationale:
Forcing fluids to 3000 mL/day to decrease inflammation is not a recommended action for managing pain due to acute pericarditis.
Choice D rationale:
Providing a fresh ice bag every hour for the patient to place on the chest is not a recommended action for managing pain due to acute pericarditis.
So, the correct answer is B, after analyzing all choices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","F"]
Explanation
Choice A rationale:
The client’s temperature decreased from 37.6°C to 36.8°C1. This is within the normal body temperature range of 36.5°C to 37.2°C2, so it does not require further action.
Choice B rationale:
The client’s oxygen saturation decreased from 95% to 88%1. Normal pulse oximetry values are typically above 95%2. This decrease could indicate that the client is not getting enough oxygen, which requires further action.
Choice C rationale:
The client’s blood pressure increased from 108/50 mm Hg to 138/80 mm Hg. Normal blood pressure for adults is below 120/80 mm Hg. This increase could indicate worsening heart failure, which requires further action.
Choice D rationale:
The client’s weight increased from 80 kg to 82.1 kg. Rapid weight gain may be a sign of fluid retention, a common symptom of heart failure. This requires further action.
Choice E rationale:
The client’s urine output decreased from 480 mL/8 hr to 320 mL/8 hr.However it is still above 30ml/hr signifying normal renal function
Choice F rationale:
On Day 4, the client’s breath sounds were scattered, and crackles were heard bilaterally. This could indicate fluid accumulation in the lungs, a common symptom of heart failure. This requires further action.
So, the correct answer is Choices B, C, D, and F, after analyzing all choices.
Correct Answer is D
Explanation
Choice A rationale:
While aspirin is often given to patients with suspected myocardial infarction, asking if the patient took aspirin does not help determine the timing of the onset of symptoms.
Choice B rationale:
Knowing the patient’s allergies is important for medication safety, but it does not help determine eligibility for thrombolytic therapy.
Choice C rationale:
Rating the pain on a scale helps assess the severity of the pain, but it does not provide information about the timing of the onset of symptoms.
Choice D rationale:
The time of pain onset is crucial in determining eligibility for thrombolytic therapy. Thrombolytic therapy is most effective when given within a certain time frame from the onset of symptoms.
So, the correct answer is D, after analyzing all choices.
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