During the acute phase of rheumatic fever, which of the following is a priority action of the nurse?

Correct Answer: B

Rationale: The correct answer is B because during the acute phase of rheumatic fever, the priority action of the nurse is to assess for early signs of endocarditis due to the risk of developing heart valve damage. Endocarditis is a serious complication of rheumatic fever that can lead to further cardiac issues. Monitoring for signs such as new or changing heart murmurs, fever, and signs of embolization is crucial for early detection and intervention. Choice A is incorrect because although ambulation is important for overall health, it is not the priority during the acute phase of rheumatic fever. Choice C is also incorrect as maintaining hydration is essential, but it is not the priority over monitoring for endocarditis. Choice D is incorrect as managing pain with strong narcotic analgesics is not the priority action during the acute phase of rheumatic fever.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates the patient's understanding of the importance of avoiding electromagnetic interference, which can disrupt the functioning of the pacemaker. Handling the pacemaker leads at the same time as the toaster can generate electromagnetic interference. Option B is incorrect because obtaining a medic alert tag is important for emergency identification but does not directly relate to pacemaker care. Option C is incorrect as the patient should always be vigilant about infection risks regardless of where the pacemaker was implanted. Option D is incorrect as modern pacemakers are designed to withstand low levels of microwave radiation and being around a home microwave is generally safe.

Correct Answer: B

Rationale: In this scenario, the correct answer is option B) Pain or dyspnea occur. This is the most appropriate response because pain or dyspnea during exercise can indicate a significant issue with the cardiovascular system. It could be a sign of angina, myocardial infarction, or another serious cardiac event that requires immediate attention. Stopping exercise when experiencing these symptoms is crucial for the patient's safety. Option A) The HR exceeds 150 beats per minute is not the best choice because heart rate can vary greatly depending on the individual's fitness level. While exceeding 150 bpm may be a concern for some, it is not a definitive indicator to stop exercise for all patients. Option C) The respiratory rate increases to 30 breaths per minute is also not as critical as option B. An increased respiratory rate could be due to factors other than cardiac issues, such as poor fitness level or environmental conditions. Option D) The HR is 15 beats over the resting heart rate is a vague and arbitrary measure. It does not account for individual variability in heart rate response to exercise and may not accurately reflect the patient's physiological limits. In an educational context, it is important to teach patients in cardiac rehabilitation programs about the signs and symptoms that warrant stopping exercise. Understanding these warning signs can help prevent serious complications and promote safe participation in physical activity. Encouraging patients to listen to their bodies and seek medical attention if they experience pain or difficulty breathing during exercise is essential for their well-being.

Correct Answer: C

Rationale: In this scenario, the most immediate action is required for option C) Oxygen saturation 91%. This is because a low oxygen saturation level indicates that the patient is not receiving enough oxygen, which can be a critical indicator of cardiac or respiratory distress during a stress test. Option A) Blood pressure 152/88 is elevated but not an immediate concern unless it continues to rise significantly. Option B) Sinus tachycardia, rate 134 is a common response to exercise and may not require immediate action unless it becomes excessively high or symptomatic. Option D) Chest pain level 3 is significant but not as immediately concerning as low oxygen saturation. Educationally, understanding the importance of monitoring oxygen saturation during stress tests is crucial for healthcare professionals to ensure patient safety and prompt intervention if necessary. It highlights the need for continuous assessment and the ability to prioritize interventions based on critical indicators of patient well-being.

Correct Answer: A

Rationale: In this scenario, the best patient to assign to the new graduate RN is option A, the 19-year-old with rheumatic fever who needs discharge teaching. This patient is stable, requiring education on self-care and transitioning home, which aligns with the new graduate's skill set and the focus of their orientation program. By providing discharge instructions, the new nurse can reinforce their learning and develop their patient teaching skills. Option B, the 33-year-old with endocarditis receiving IV ceftizoxime, is not ideal for the new graduate as it involves administering a high-risk medication that requires advanced knowledge and experience. Option C, the 50-year-old with stable angina, although stable, has complex medication and care needs that may overwhelm a new graduate. Option D, the 75-year-old post-coronary artery bypass grafting, is also not suitable due to the recent surgery and potential for post-operative complications that require a higher level of expertise. Educationally, assigning appropriate patient assignments is crucial for new graduates to build confidence, competence, and critical thinking skills. By matching patient acuity and complexity with the nurse's level of experience, we support their professional growth and ensure safe and effective care delivery.