Upon auscultating a patient's heart sounds, the nurse is concerned that a pericardial friction rub is present. Which health problem should the nurse suspect is possibly occurring in this patient?
a. Pleurisy
b. Pneumonia
c. Mitral valve prolapse
d. Myocardial infarction
ANS: D
A pericardial friction rub may occur after a myocardial infarction or chest trauma. A. B. C. A pericardial friction rub is not associated with these health problems.
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The charge nurse on the medical/surgical unit is reviewing physician orders for a client with a diagnosis of congestive heart failure. Which infusion orders would the nurse question?
A) 50 mL D5W to run in 60 minutes B) 250 mL 0.9 NaCl to run in 60 minutes C) 1000 D5W to run in 30 minutes D) 20 mL 0.9 NaCl to run in 20 minutes
An enema is given
A. to remove feces from the colon and rectum. B. to flush the stomach before surgery. C. to cleanse the stoma and ostomy. D. immediately after a meal.
Several hours later, K.Z. returns from his catheterization
The catheterization report shows 90% occlusion of the proximal left anterior descending (LAD) coronary artery, 90% occlusion of the distal LAD, 70% to 80% occlusion of the distal right coronary artery (RCA), an old apical infarct, and an ejection fraction (EF) of 37%. About an hour after the procedure is finished, you perform a brief physical assessment and note a grade III/VI systolic ejection murmur at the cardiac apex, crackles bilaterally in the lung bases, and trace pitting edema of his feet and ankles. Except for the soft systolic murmur, these findings were not present before the catheterization. What is your evaluation of the catheterization results? Explain the significance of having an EF of 37%. What problem do the changes in assessment findings suggest to you? What led you to your conclusion? List five actions you should take as a result of your evaluation of the assessment, and state your rationales.
The nurse is caring for a 65-year-old Jehovah's Witness who is having severe gastrointestinal bleeding. The patient's hemoglobin is dangerously low
The patient, who is fully alert and competent, refuses to accept the blood transfusion ordered by the physician. Which action by the nurse is most appropriate? a. Ensure the patient understands possible consequences, and then respect the patient's wishes. b. Obtain a court order to give the blood. c. Have the patient's spouse sign the consent to have the blood administered. d. Administer the blood while the patient is sleeping.