Assessment findings for a patient with acute pericarditis indicate neck vein distention, clear lungs, muffled heart sounds, tachycardia, tachypnea, and a greater than 10 mm Hg difference in systolic pressure on inspiration than on expiration. What is the nurse's first response to these assessment findings?
a. Continue to monitor the patient; these are normal signs of pericarditis.
b. Administer oxygen and immediately report the findings to the health care provider.
c. Monitor oxygen saturation and seek order for pain medication to control symptoms.
d. Check ECG, administer morphine for pain, and administer diuretics.
Answer: b. Administer oxygen and immediately report the findings to the health care provider.
You might also like to view...
Which are the phases of wound healing? (Select all that apply.)
a. Reconstruction b. Hemostasis c. Inflammation d. Granulation e. Maturation
Which assessment data should a school nurse recognize as a sign of physical neglect?
1. The child is often absent from school and seems apathetic and tired. 2. The child is very insecure and has poor self-esteem. 3. The child has multiple bruises on various body parts. 4. The child has sophisticated knowledge of sexual behaviors.
A nursing instructor has asked a group of students to develop teaching plans for their clients according to Gagne's nine elements
If the instructor asks the students about some of the components of Gagne's events of instruction, which response by a student would indicate that further teaching is needed? a. Gain attention c. Implement performance b. Present stimulus materials d. Provide feedback
At a well-child visit, the mother of a 2-year-old asks about diet information. The child needs a 1000-calorie diet. The nurse informs the mother that:
a. Her child needs 4 to 5 cups of milk per day b. Her child needs 23 grams of protein per day c. Her child needs to drink skim milk or low-fat milk d. Her child needs to drink whole milk