A patient recovering from a myocardial infarction (MI) develops cheat pain on day 3 that increases when taking a deep breath, lying flat, and is relieved by leaning forward. Which additional assessment data should the nurse collect next?

Auscultate for a pericardial friction rub

Inspect the skin for petechia

Palpate the radial pulses bilaterally

Assess for abdominal pain

Answer and Explanation

The Correct Answer is A

A. Auscultate for a pericardial friction rub: These symptoms are classic for pericarditis, a complication of MI. A pericardial friction rub is a key diagnostic finding.

B. Inspect the skin for petechiae: Petechiae are associated with conditions like infective endocarditis or thrombocytopenia, not pericarditis.

C. Palpate the radial pulses bilaterally: Assessing radial pulses is essential for circulation but does not directly relate to pericarditis symptoms.

D. Assess for abdominal pain: Abdominal pain is not typical of pericarditis and would not be the priority assessment.

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Correct Answer is B

Explanation

A. To increase hydration: This is not a priority in terminal care. In fact, increasing hydration can be uncomfortable for dying patients who are often unable to process fluids effectively.

B. To control symptoms: The primary focus in end-of-life care is to manage symptoms, such as pain, difficulty breathing, and anxiety, to ensure the patient is as comfortable as possible.

C. To promote nutrition: At the end of life, promoting nutrition is usually not the priority, as the client may no longer desire food and may be unable to tolerate it.

D. To limit environmental hazards: While important, it is not the priority in terminal care. The focus should be on comfort and symptom control.

A. Bring the crash cart to the bedside B. Start Cardiopulmonary resuscitation. C. Defibrillate the client D. Administer Adenosine (Adenocard) to assist in determining the patient's rhythm E. Consider the "Hs and Ts" (reversible causes of cardiac arrest) to determine appropriate treatment.

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

Explanation

A. Bring the crash cart to the bedside: Essential for advanced cardiac life support (ACLS), including defibrillation and medications.

B. Start cardiopulmonary resuscitation: High-quality CPR is critical to maintain circulation until defibrillation can occur.

C. Defibrillate the client: Defibrillation is the definitive treatment for ventricular fibrillation to restore a normal rhythm.

D. Administer adenosine (Adenocard) to assist in determining the rhythm: Adenosine is used for diagnosing or treating certain supraventricular tachycardias, not ventricular fibrillation.

E. Consider the "Hs and Ts": Identifying reversible causes of cardiac arrest (e.g., hypoxia, hypothermia, toxins) is part of the ACLS protocol.

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A patient recovering from a myocardial infarction (MI) develops cheat pain on day 3 that increases when taking a deep breath, lying flat, and is relieved by leaning forward. Which additional assessment data should the nurse collect next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is terminally and approaching the end of life. Which goal would the nurse identify as the priority?

Correct Answer is B

Explanation

The client is found in ventricular fibrillation. What interventions should the team implement? Select All That Apply

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

Explanation

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