You are providing care to a patient with pericarditis.
Which of the following is NOT a proper nursing intervention for this patient?
Administer Ibuprofen as scheduled.
Monitor the patient for complications of cardiac tamponade.
Place the patient in a supine position to relieve pain.
Monitor the patient for pulsus paradoxus and muffled heart sounds.
The Correct Answer is C
Choice A rationale
Administering Ibuprofen as scheduled is a proper nursing intervention for a patient with pericarditis. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can help reduce inflammation and relieve pain.
Choice B rationale
Monitoring the patient for complications of cardiac tamponade is a proper nursing intervention for a patient with pericarditis. Cardiac tamponade is a serious condition that can occur as a complication of pericarditis.
Choice C rationale
Placing the patient in a supine position to relieve pain is not a proper nursing intervention for a patient with pericarditis. This position could actually increase the patient’s discomfort.
Instead, the patient should be positioned upright and leaning forward to help relieve pain.
Choice D rationale
Monitoring the patient for pulsus paradoxus and muffled heart sounds is a proper nursing intervention for a patient with pericarditis. These are potential signs of worsening pericarditis or complications such as cardiac tamponade.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Orthostatic hypotension, a form of low blood pressure that happens when you stand up from sitting or lying down, would not typically cause severe chest pain or result in elevated levels of cardiac troponins I and T6.
Choice B rationale
Raynaud’s disease, a condition that causes some areas of your body — such as your fingers and toes — to feel numb and cold in response to cold temperatures or stress, would not typically cause severe chest pain or result in elevated levels of cardiac troponins I and T6.
Choice C rationale
Angina, a type of chest pain caused by reduced blood flow to the heart, could cause severe chest pain, but it would not typically result in elevated levels of cardiac troponins I and T6. Elevated troponin levels are more indicative of damage to the heart muscle, which is not characteristic of angina.
Choice D rationale
A myocardial infarction (MI), also known as a heart attack, could cause severe chest pain and would typically result in elevated levels of cardiac troponins I and T7. Troponins are proteins found in the heart muscle, and levels can rise in the blood when there is damage to the heart, such as during an MI.
Correct Answer is A
Explanation
Choice A rationale
A 59-year-old patient with unstable angina who has just returned from a percutaneous coronary intervention (PCI) should be prioritized for assessment. PCI is a procedure to open blocked or narrowed coronary arteries and can lead to complications such as re-occlusion of the artery or bleeding from the catheter insertion site. Furthermore, unstable angina is a condition that can progress to myocardial infarction if not managed effectively.
Choice B rationale
A 56-year-old patient with variant angina due to receive nifedipine (Procardia) requires monitoring, but is not the highest priority. Variant angina is a form of angina that occurs at rest, often with severe pain, but it is usually well-controlled with medications like nifedipine.
Choice C rationale
A 65-year-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about discharge planned for today is a lower priority for assessment. While it’s important to address the patient’s anxiety and provide education about post-discharge care, this patient is not in immediate danger.
Choice D rationale
A 39-year-old patient with pericarditis complaining of sharp, stabbing chest pain requires assessment, but is not the highest priority. Pericarditis is inflammation of the pericardium, the sac-like covering of the heart, and while it can cause severe pain, it is not typically life- threatening.
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