The nurse is planning care for a client with pericarditis. Which intervention assesses for the potential complication of cardiac tamponade?

Check current WBC count

Assess for hypertension

Auscultate heart sounds

Measure blood glucose

Answer and Explanation

The Correct Answer is C

a. Check current WBC count: While an elevated white blood cell (WBC) count may indicate inflammation, it is not specific to the assessment of cardiac tamponade. WBC count may be elevated in pericarditis due to the inflammatory process, but it does not directly assess for the potential complication of cardiac tamponade.

b. Assess for hypertension: Hypertension is not typically associated with cardiac tamponade. Instead, cardiac tamponade is characterized by hemodynamic compromise, which may manifest as hypotension rather than hypertension. While assessing blood pressure is important in overall cardiovascular assessment, it is not specific to detecting cardiac tamponade.

c. Auscultate heart sounds: Auscultating heart sounds, specifically for the presence of muffled heart sounds (reduced intensity of heart sounds) and distant heart sounds, is a key assessment for detecting cardiac tamponade, a potential complication of pericarditis. Cardiac tamponade occurs when fluid accumulates in the pericardial sac, compressing the heart and impairing cardiac filling. This can lead to hemodynamic compromise and potentially life-threatening consequences. Muffled or distant heart sounds are classic signs of cardiac tamponade and indicate the need for immediate intervention.

d. Measure blood glucose: Blood glucose measurement is not directly related to the assessment of cardiac tamponade. While monitoring blood glucose levels may be important in clients with diabetes or those at risk of hyperglycemia, it does not provide information specific to the detection of cardiac tamponade.

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Correct Answer is B

Explanation

Based on the expected changes in hyperventilation related to anxiety, option b (pH 7.47, PaCO2 25 mmHg, HCO3 26 mEq/L) is the most consistent with respiratory alkalosis, which occurs due to hyperventilation:

a. pH 7.49, PaCO2 36 mmHg, HCO3 31 mEq/L:

The pH is higher than the normal range, indicating alkalosis.
The PaCO2 is within the normal range (slightly elevated), which is unexpected in hyperventilation where PaCO2 is typically decreased.
The HCO3 is elevated, indicating metabolic alkalosis, which is not typically associated with hyperventilation related to anxiety.

b. pH 7.47, PaCO2 25 mmHg, HCO3 26 mEq/L:

The pH is higher than the normal range, indicating alkalosis.
The PaCO2 is below the normal range, indicating respiratory alkalosis, which is consistent with hyperventilation.
The HCO3 is within the normal range, which can occur as a compensatory mechanism for respiratory alkalosis.

c. pH 7.32, PaCO2 41 mmHg, HCO3 22 mEq/L:

The pH is lower than the normal range, indicating acidosis.
The PaCO2 is within the normal range, which is unexpected in hyperventilation where PaCO2 is typically decreased.
The HCO3 is within the normal range, indicating compensated metabolic acidosis, which is not typically associated with hyperventilation related to anxiety.

d. pH 7.30, PaCO2 48 mmHg, HCO3 26 mEq/L:

The pH is lower than the normal range, indicating acidosis.
The PaCO2 is elevated, indicating respiratory acidosis, which is not typically associated with hyperventilation.
The HCO3 is within the normal range, which can occur as a compensatory mechanism for respiratory acidosis.

A. Assess level of consciousness B. Monitor serum sodium C. Check skin turgor D. Administer diuretics

Correct Answer is A

Explanation

a. Assess level of consciousness: Respiratory acidosis in COPD patients can lead to hypercapnia (elevated carbon dioxide levels), which may result in altered mental status, confusion, or decreased level of consciousness due to respiratory depression. Assessing the level of consciousness is important to monitor for signs of worsening respiratory distress or impending respiratory failure.

b. Monitor serum sodium: COPD patients with respiratory acidosis may retain carbon dioxide, leading to respiratory compensation by the kidneys through increased retention of bicarbonate ions. This retention of bicarbonate can result in metabolic alkalosis and potentially affect electrolyte balance, including sodium levels. Monitoring serum sodium levels is essential to detect any electrolyte imbalances that may occur as a result of respiratory acidosis and its compensatory mechanisms.

c. Check skin turgor: While checking skin turgor is a valuable assessment for hydration status, it may not be directly related to respiratory acidosis in COPD. However, it's still important to assess hydration status in COPD patients, especially those with exacerbations, as dehydration can exacerbate respiratory symptoms.

d. Administer diuretics: Diuretics are not typically indicated in the management of respiratory acidosis in COPD. In fact, diuretics can worsen respiratory acidosis by potentially causing volume depletion and further reducing effective gas exchange in already compromised lungs. Diuretics may be used cautiously in COPD patients with concomitant heart failure or volume overload, but their use should be carefully monitored and individualized.

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The nurse is planning care for a client with pericarditis. Which intervention assesses for the potential complication of cardiac tamponade?

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Naxlex Comprehensive Predictor Exams

A client in the emergency department is being treated for hyperventilation related to anxiety. Which arterial blood gas result would the nurse anticipate for this client? Normal arterial blood gas values pH: 7.35-7.45, PaCO2: 35-45mmHg, HCO3: 22-26mEq/L.

Correct Answer is B

Explanation

Which intervention would the nurse include in the plan of care for a client with COPD and respiratory acidosis?

Correct Answer is A

Explanation

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