A patient is admitted with acute pericarditis and reports severe chest pain. The nurse identifies the nursing diagnosis fo Acute pain related to the inflammatory process. Which nursing action is most appropriate to relieve the patient's pain?
Administer opioid analgesics every 4 hours.
Increase fluid intake to reduce inflammation
Place the patient in Fowler's position, leaning forward.
Encourage the patient to take deep, slow breaths
The Correct Answer is C
A. Administer opioid analgesics every 4 hours: Opioids can reduce pain but do not address the positional component of pericardial pain, which often worsens with lying supine or deep inspiration. Opioids may be considered if NSAIDs or positioning strategies are insufficient, but they are not the first-line intervention for pain specifically caused by pericardial inflammation.
B. Increase fluid intake to reduce inflammation: While maintaining hydration is generally important, increasing fluid intake does not directly reduce pericardial inflammation or relieve the acute chest pain associated with pericarditis. This action has minimal impact on the patient’s immediate discomfort.
C. Place the patient in Fowler's position, leaning forward: Leaning forward and sitting upright relieves pericardial pain by decreasing pressure on the inflamed pericardial sac and reducing friction between pericardial layers. This position is a non-pharmacologic, evidence-based intervention specifically effective in alleviating pericarditis-related chest pain.
D. Encourage the patient to take deep, slow breaths: Deep breathing may exacerbate pericarditis pain because chest expansion increases friction of the inflamed pericardial layers. While breathing exercises are generally useful in other conditions, they are not recommended as a primary strategy for acute pericarditis pain relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Begin cardiopulmonary resuscitation: Asystole indicates a complete absence of ventricular electrical activity, and the patient is pulseless and apneic. Immediate initiation of high-quality CPR is critical to maintain circulation and oxygen delivery to vital organs while advanced resuscitative measures are prepared. Early CPR improves the chance of return of spontaneous circulation.
B. Prepare to defibrillate: Defibrillation is effective for shockable rhythms such as ventricular fibrillation or pulseless ventricular tachycardia. Asystole is a non-shockable rhythm, so defibrillation would not restore cardiac activity and would delay essential CPR.
C. Begin rescue breathing with bag-valve-mask: While providing oxygenation is important, in a pulseless patient, chest compressions take priority over rescue breathing. CPR ensures perfusion of the brain and heart until advanced life support interventions can be applied.
D. Prepare to cardiovert: Synchronized cardioversion is indicated for unstable tachyarrhythmias such as atrial fibrillation or supraventricular tachycardia. It is not appropriate for asystole, which requires immediate CPR and administration of medications such as epinephrine under advanced life support protocols.
Correct Answer is B
Explanation
A. BP 102/56 mm Hg: This blood pressure is slightly low but may still be sufficient to maintain perfusion in some patients. Early compensatory mechanisms in shock can maintain perfusion despite borderline hypotension, so while it warrants monitoring, it is not the most critical finding.
B. Urine output 15 ml for 2 hours: Oliguria is a sensitive early indicator of inadequate tissue perfusion in shock. A urine output of less than 0.5 mL/kg/hr reflects decreased renal perfusion and potential impending acute kidney injury, making this the most urgent finding requiring immediate assessment and intervention.
C. Arterial oxygen saturation 92%: Oxygen saturation of 92% is mildly reduced and may indicate early hypoxemia. While concerning, it is less immediately critical than evidence of end-organ hypoperfusion, such as severely reduced urine output.
D. Apical pulse 110 beats/min: Tachycardia is a compensatory response in shock to maintain cardiac output. While it signals stress on the cardiovascular system, it is expected in early shock and is less immediately dangerous than oliguria indicating organ hypoperfusion.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.