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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While assessing the gag reflex is important in certain situations, such as after surgery involving anesthesia, it is not typically a crucial assessment following Percutaneous Transluminal Angioplasty (PTA) of the lower extremity.
Choice B rationale
Checking for dye allergies is important before a procedure that uses contrast dye. However, it is not a crucial post-procedure assessment.
Choice C rationale
Monitoring of pedal pulses is crucial following PTA of the lower extremity. This is because the procedure involves the arteries in the legs, and monitoring pedal pulses can help assess blood flow to the area and detect potential complications such as occlusion or clot formation.
Choice D rationale
While the Ankle-Brachial Index can be used to diagnose Peripheral Arterial Disease (PAD), it is not typically a crucial assessment immediately following PTA3.
Correct Answer is D
Explanation
The symptoms described - tachycardia, severe dyspnea, diaphoresis, crackles, and profuse, frothy pink sputum - are indicative of acute pulmonary edema, a condition characterized by fluid accumulation in the lungs due to heart failure. In this situation, the Fowler’s position (sitting up at a 45-60 degree angle) with legs lowered is recommended. This position helps to reduce venous return to the heart, thereby decreasing the workload on the heart and helping to alleviate symptoms.
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