Gig em
Question 2: Acute Pericarditis
A nurse is caring for a client admitted with acute pericarditis. Which assessment finding requires immediate emergency intervention by the nurse?
A nurse is performing a physical assessment on a client with peripheral artery disease (PAD). Which clinical finding should the nurse expect to observe in the lower extremities?
A nurse is providing discharge teaching to a client diagnosed with severe COPD (emphysema and chronic bronchitis). Which statement by the client indicates a correct understanding of the disease management and medical orders?
A nurse is teaching a client who has been prescribed ibuprofen for inflammation. Which finding should the nurse instruct the client to report immediately?
b) black tarry stools
(GI bleeding!!!)
A client with dilated cardiomyopathy is admitted with worsening heart failure. Which pathophysiological mechanism and assessment finding should the nurse anticipate?
A nurse is assessing a client with peripheral artery disease (PAD). Which finding would the nurse expect?
A. Warm, flushed extremities with bounding pulses
B. Cool, pale extremities with decreased peripheral pulses
C. Bilateral dependent edema that improves with standing
D. Brown discoloration around the ankles with thickened skin
B. Cool, pale extremities with decreased peripheral pulses
Rationale: PAD involves reduced arterial blood flow to the extremities. Findings can include cool, pale extremities and diminished pulses.
A for Absent Pulses
A nurse is caring for a client with COPD who is experiencing increased shortness of breath. Which intervention should the nurse prioritize? (SATA)
A. Encourage the client to lie flat
B. Encourage pursed-lip breathing
C. Restrict all oral fluids
D. Raise head of bed to 30-45 degrees
B, D: Encourage pursed lip breathing and raise head of bed to 30-45 degrees
A nurse is teaching a client who is taking aspirin. Which statement by the client indicates a need for further teaching?
A. “I should report unusual or prolonged bleeding.”
B. “I should take aspirin exactly as prescribed.”
C. “I can take additional ibuprofen whenever I have pain without discussing it with my provider.”
D. “I should report signs of gastrointestinal bleeding.”
C. “I can take additional ibuprofen whenever I have pain without discussing it with my provider.”
Rationale: Aspirin and ibuprofen are both NSAIDs. Taking them together can increase the risk of GI irritation/bleeding and other adverse effects. The client should discuss additional NSAID use with the provider.
A patient walks into the hospital and the nurse notes shortness of breath, orthopnea, and persistent cough. What should the nurse suspect?
a) PAD
B) acute MI
C) Right sided Heart failure
d) Left sided Heart Failure
Think L for Lungs!
A nurse is caring for a client with dilated cardiomyopathy. Which complication is the client at increased risk for because blood can stagnate in the dilated ventricles?
A. Thrombus formation
B. Hyperthyroidism
C. Pericardial friction rub
D. Increased cardiac contractility
A) thrombus formation
In dilated cardiomyopathy, the ventricles become dilated and contractility decreases. Blood can stagnate, increasing the risk of thrombus formation
A nurse is caring for a client with COPD who is prescribed ipratropium. Which adverse effect should the nurse monitor for?
A. Excessive salivation
B. Urinary retention
C. Severe hypoglycemia
D. Increased bowel motility
B. urinary retention
Ipratropium is an anticholinergic medication. Urinary retention, dry mouth, and increased intraocular pressure as adverse effects.
A nurse is assessing a client who is taking aspirin. Which finding requires the nurse's priority attention?
A. Mild nausea after taking the medication
B. Tinnitus
C. Increased appetite
D. Mild thirst
b) Tinnitus can be a sign of salicylate toxicity.
unusual bleeding is also a sign that should be priority
A nurse is caring for a client who has acute pericarditis. Which finding should the nurse expect?
B. Sharp chest pain relieved by sitting up and leaning forward
A nurse is discussing the plan of care with a patient diagnosed with PAD. The nurse should emphasize what action regarding exercise?
a) the patient should avoid moving the leg
b) the patient should massage the leg after exercising
c) the patient should rest when intermittent claudication occurs
d) the patient should ignore pain since exercise will reduce the pain
c) the patient should rest when intermittent claudication occurs
After the pain passes the patient should resume their exercise
A client with COPD is prescribed theophylline. Which finding should the nurse recognize as a possible indication of theophylline toxicity?
A. Mild thirst
B. Seizures and dysrhythmias
C. Decreased heart rate
D. Urinary retention
B) Seizures and dysrhythmias
seizures and dysrhythmias as possible adverse effects when theophylline reaches toxic levels
What is a secondary effect of Aspirin?
A) increased platelet production
B) decreased platelet aggregation
C) Inflammation
D) Lower Heart rate
b) decreased platelet aggregation
prevents clot formation
A nurse is assessing a client with acute pericarditis. Which assessment finding is the hallmark of this condition?
A. Squeaky sound when using stethoscope
B. Bounding peripheral pulses
C. Systolic murmur
D. Crackles that disappear with coughing
A) Squeaky sound when using stethoscope
Pericardial friction rub is a squeaky/leathery sound caused by inflammation
What are the clinical manifestations of PVD?
LIST THEM at least 3
brown coloration
lower leg edema
sores around ankles
pulse present
Drainage
A nurse is caring for a client with COPD who has been prescribed ipratropium. Which client statement indicates that the nurse should provide further teaching?
A. “I should report difficulty urinating.”
B. “I should have regular eye examinations.”
C. “I can use water or hard candy to help with dry mouth.”
D. “I should expect this medication to increase my urine output.”
D) i should expect this medication to increase my urine output
It can cause urinary retention, not increased urine output.
The nurse is caring for four clients who are taking ibuprofen. Which client should the nurse assess first?
A. A client who reports mild nausea after taking the medication
B. A client who reports ringing in the ears after taking the medication
C. A client who reports black, tarry stools and dizziness
D. A client who reports mild stomach discomfort after taking the medication
c) a client who reports black, tarry stools, and dizziness
gi bleeding