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 D

Explanation

a. Check groin dressing: While monitoring the dressing is important, it is not the top priority immediately after the procedure. The nurse should assess other critical aspects first.
b. Review current H&H (hemoglobin and hematocrit): Although monitoring hemoglobin and hematocrit levels is essential, it is not the highest priority at this moment. Immediate post-procedure concerns take precedence.
c. Check blood glucose: Blood glucose monitoring is important, especially if the client has diabetes or other risk factors. However, it is not the priority right after the procedure.
d. Assess pain level: This is the priority intervention. The nurse should assess the client’s pain level, especially at the insertion site. Pain could indicate complications such as bleeding, hematoma, or vascular injury.

A. Assess for decreased respiratory rate B. Diet teaching to include low protein foods C. Obtain daily weight D. Check blood glucose

Correct Answer is A

Explanation

Metabolic alkalosis is an acid-base imbalance characterized by excessive loss of acid or excessive gain of bicarbonate produced by an underlying pathologic disorder. It's essential to address this condition promptly.

a. Assess for decreased respiratory rate: Metabolic alkalosis leads to hypoventilation as the body compensates by retaining carbon dioxide. Monitoring respiratory rate is crucial to detect any signs of respiratory distress or inadequate ventilation¹.

- Priority: High

b. Diet teaching to include low protein foods: While dietary adjustments are important, addressing the underlying cause (such as vomiting, diuretic use, or excessive alkali intake) is more critical. Low protein foods alone won't correct metabolic alkalosis.

- Priority: Low

c. Obtain daily weight: Daily weight monitoring is essential for assessing fluid balance, but it doesn't directly address metabolic alkalosis. Other interventions take precedence.

- Priority: Medium.

d. Check blood glucose: Blood glucose levels are not directly related to metabolic alkalosis. Focusing on acid-base balance and electrolyte levels is more relevant.

- Priority: Low

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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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