The nurse is caring for a client after a heart catheterization. What complication must the nurse intervene for immediately?

2+ bilateral peripheral edema

Heart rate 59 beats/min

Temperature of 96 F

Muffled heart sounds

Answer and Explanation

The Correct Answer is D

A. Bilateral peripheral edema can occur after heart catheterization but is not as immediately life-threatening as cardiac tamponade.

B. A heart rate of 59 beats/min may be concerning, but bradycardia alone is not as immediately urgent as signs of cardiac tamponade.

C. A temperature of 96°F is low, but this is more of a concern for hypothermia or post-procedural effects and is not as urgent as muffled heart sounds indicating tamponade.

D. Muffled heart sounds can indicate cardiac tamponade, a medical emergency. Immediate intervention is required to relieve the pressure on the heart, which may involve pericardiocentesis to drain the fluid or blood.

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Correct Answer is D

Explanation

A. Administering multiple vitamins and minerals via IV alone would not be sufficient for adequate nutrition in this patient, especially given the large burn surface area.

B. Total parenteral nutrition (TPN) may be used if enteral feeding is not possible, but enteral feeding is usually preferred when feasible.

C. Encouraging oral intake is not appropriate for a client with a 60% TBSA burn, as they would likely require more significant nutritional support than oral intake can provide.

D. Enteral feeding is the preferred method for nutrition in burn patients as it maintains gut integrity and prevents the complications associated with parenteral nutrition. Although the client has absent bowel sounds and a distended abdomen, this can be common early in burn care, and enteral feedings should be started as soon as feasible to prevent malnutrition and promote recovery.

A. Stool frequency B. Fecal occult test C. Bowel sounds D. Abdominal distention

Correct Answer is B

Explanation

A. Stool frequency does not directly evaluate the prevention of stress ulcers or gastrointestinal bleeding.

B. Fecal occult test directly assesses for hidden gastrointestinal bleeding, making it the best evaluation method.

C. Bowel sounds, while important for general gastrointestinal assessment, bowel sounds do not directly evaluate the effectiveness of Esomeprazole in preventing bleeding.

D. Abdominal distention may indicate a variety of issues but is not specific to assessing the effectiveness of a proton pump inhibitor.

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Test Name	Results	Reference Range
WBC	12, 000	4, 000- 11, 000
Na+	149 mEq/L	135-145 mEq/L
K+	5.0 mEq/L	3.5- 5.0 mEq/L
Cl-	110 mEq/L	96-106 mEq/L
pH	7.34	7.35-7.45
PaCO2	34 mmHg	35- 45 mmHg
PaO2	78 mm Hg	80-100 mmHg
HCO3	21 mEq/L	22- 26 mEq/L

The nurse is caring for a client after a heart catheterization. What complication must the nurse intervene for immediately?

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Naxlex Comprehensive Predictor Exams

A client has just been admitted with a 60% total body surface area (TBSA) burn injury. The nurse notes a distended abdomen with absent bowel sounds in all quadrants. To maintain adequate nutrition, the nurse should plan to take which action?

Correct Answer is D

Explanation

The proton pump inhibitor Esomeprazole (Nexium) is prescribed for a client who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the drug?

Correct Answer is B

Explanation

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