The physician prescribes 0.15 mg of digoxin IV push for a heart failure patient.

The available dose is 1 mg/1 ml. How many milliliters will the nurse administer?

Choice A rationale

Elevating the legs is contraindicated for a client with an aneurysm because it can increase venous return and subsequently increase the pressure within the arterial system. For an abdominal or thoracic aneurysm, the goal is to keep systemic blood pressure low and stable to prevent wall stress. Bedrest is often encouraged, but the legs should remain flat or in a neutral position to avoid any unintended increases in central venous or arterial pressures.

Choice B rationale

Administering antihypertensive medications and beta blockers is a standard evidence based intervention for managing aneurysms. These drugs work by lowering the systemic blood pressure and reducing the heart rate, which decreases the force of blood hitting the weakened vessel wall. By minimizing the dP/dt, or the rate of pressure rise, these medications significantly reduce the risk of dissection or rupture. Maintaining a systolic blood pressure within a narrow, low range is the clinical priority.

Choice C rationale

Preventing straining during defecation is crucial because the Valsalva maneuver significantly increases intra abdominal and intra thoracic pressure. This sudden spike in pressure can place excessive stress on the aneurysmal sac, potentially leading to an immediate rupture. Nurses provide stool softeners and educate clients on proper breathing techniques to ensure that they do not hold their breath or exert themselves physically, thereby maintaining a stable and safe internal pressure environment.

Choice D rationale

Psychological stress triggers the sympathetic nervous system, leading to the release of cortisol and adrenaline. These hormones cause vasoconstriction and increase the heart rate and blood pressure, all of which increase the tension on the arterial wall. By maintaining a calm environment and using stress reduction techniques, the nurse helps keep the client's hemodynamics stable. This holistic approach is essential for preventing the physiological spikes that lead to the catastrophic failure of the aneurysm.

Choice A rationale

Pulmonary edema occurs when fluid backs up into the lungs, usually due to left-sided heart failure. While pericardial fluid can affect heart function, pulmonary edema is not the most immediate or direct complication of fluid accumulation within the pericardial sac itself. Instead, the fluid in the sac creates external pressure on the heart. The focus of care for increased pericardial fluid is the restriction of cardiac filling rather than the primary congestion of the pulmonary vasculature.

Choice B rationale

Cardiac tamponade is a life-threatening condition where the accumulation of fluid in the pericardial sac increases intrapericardial pressure. This pressure prevents the heart chambers from expanding fully during diastole, which severely reduces stroke volume and cardiac output. Common signs include Beck's triad: hypotension, jugular venous distention, and muffled heart sounds. Immediate intervention is required because the heart can eventually stop beating entirely as it becomes unable to fill with blood due to external compression.

Choice C rationale

Pericarditis is the inflammation of the pericardium, which is often the underlying cause of fluid accumulation, known as pericardial effusion. While the nurse monitors for signs of inflammation, the question asks for a complication resulting from the fluid being dangerously increased. Pericarditis is the state of the tissue rather than the acute hemodynamic consequence of fluid volume. Therefore, preventing the functional collapse of the heart takes precedence over managing the inflammatory process in an emergency.

Choice D rationale

Pericardiocentesis is a medical procedure used to drain excess fluid from the pericardial sac to relieve pressure on the heart. It is a treatment modality rather than a complication. The nurse collaborates with the team to perform this procedure in order to treat or prevent cardiac tamponade. Since the question asks for a complication to prevent, choosing a treatment is logically incorrect. The goal is to avoid the physiological crisis that necessitates such an invasive intervention.