Which of the following nursing interventions should a nurse perform to relieve tachycardia that may develop in a client with myocarditis from hypoxemia?

Correct Answer: D

Rationale: In the scenario of a client with myocarditis developing tachycardia from hypoxemia, the correct nursing intervention to relieve tachycardia is option D: Administer supplemental oxygen. Tachycardia in this context is often a compensatory response to hypoxemia, where the heart rate increases to improve oxygen delivery. Providing supplemental oxygen helps to increase the oxygen saturation in the blood, alleviating the hypoxemia that is triggering the tachycardia. Option A: Maintaining the client on bed rest may be important for certain conditions, but in this case, addressing the underlying cause of hypoxemia with oxygen therapy is more crucial to relieve tachycardia. Option B: Administering a prescribed antipyretic is used to reduce fever, which is not directly related to addressing the hypoxemia-induced tachycardia. Option C: Elevating the client's head is a common intervention for promoting comfort and reducing respiratory distress but does not directly address the hypoxemia causing the tachycardia. Educationally, understanding the pathophysiology of tachycardia in the context of hypoxemia and myocarditis is crucial for nurses to provide effective care. Recognizing the appropriate interventions based on the underlying mechanisms involved is essential for optimizing patient outcomes and safety. Incorporating this knowledge into practice ensures that nurses can prioritize interventions that directly target the root cause of the issue, such as administering supplemental oxygen in this scenario.

Correct Answer: C

Rationale: In this case, the correct answer is C) Supraventricular Tachycardia (SVT). SVT is characterized by a heart rate greater than 150 beats per minute, shortened diastole, and inadequate time for the heart to fill properly. This rapid rhythm originates above the ventricles and can lead to symptoms such as palpitations, chest pain, dizziness, and even syncope. Sinus bradycardia (option A) is a slow heart rhythm, not consistent with the scenario described in the question. Sinus tachycardia (option B) is a fast heart rhythm, but diastole is not shortened in this rhythm. Atrial flutter (option D) is a specific type of supraventricular arrhythmia, but it typically presents with a sawtooth pattern on ECG, which is not mentioned in the question stem. Understanding different cardiac rhythms is crucial for nurses working in telemetry units or any healthcare setting where cardiac monitoring is performed. Recognizing these rhythms promptly is essential for initiating appropriate interventions and preventing potential complications for the patient. Nurses must be adept at interpreting telemetry alarms accurately to provide timely and effective care.

Correct Answer: A

Rationale: In right-sided heart failure, the correct symptom observed is dependent pitting edema (Option A). This occurs due to fluid retention and increased venous pressure, leading to swelling in the lower extremities. Exertional dyspnea (Option B) is more commonly associated with left-sided heart failure, where there is a buildup of fluid in the lungs causing difficulty breathing during activity. Orthopnea (Option C) is also a symptom of left-sided heart failure, characterized by difficulty breathing when lying flat. Hemoptysis (Option D) is the coughing up of blood and is not typically associated with heart failure but can be a sign of other serious conditions such as pulmonary embolism or pneumonia. Educationally, understanding the distinct symptoms of left-sided versus right-sided heart failure is crucial for accurate assessment and management of patients with cardiovascular conditions. Recognizing these symptoms helps healthcare professionals provide appropriate interventions and improve patient outcomes.

Correct Answer: D

Rationale: The correct answer is D) One or more arteries that supply blood to his heart are blocked, thereby preventing an adequate amount of blood from getting to his cardiac muscles. This response is the most appropriate because it directly addresses the patient's condition of myocardial infarction (heart attack). It provides a clear and accurate explanation in simple terms, helping the patient understand the cause of his symptoms. Option A is incorrect because leaving the patient uninformed can increase anxiety and hinder patient-provider communication. It is important to provide basic information to the patient to alleviate fear and facilitate understanding. Option B is incorrect as it refers to a congenital heart condition related to the aortic valve, which is not relevant to the patient's current situation of myocardial infarction. Option C is incorrect and promotes a harmful stereotype that overweight individuals are destined to have a heart attack. This statement lacks medical accuracy and can contribute to patient stigma. Educational context: In healthcare, effective communication with patients is essential for building trust, ensuring informed decision-making, and promoting patient satisfaction. Providing clear and accurate information empowers patients to participate in their care and promotes better health outcomes. Educating patients about their condition in simple language helps them understand the importance of treatment and lifestyle modifications.

Correct Answer: D

Rationale: In the scenario of administering thrombolytic therapy to a patient with an acute myocardial infarction (MI), the primary consideration should be the time since the onset of symptoms, making option D the correct answer. Time is crucial in this situation as thrombolytic therapy is most effective when given promptly after the onset of symptoms to dissolve the blood clot causing the MI and restore blood flow to the heart muscle. Option A, history of heart disease, while important for assessing the patient's overall cardiac health, is not the primary consideration in the acute management of an MI. Option B, sensitivity to aspirin, is relevant for other aspects of treatment but not the primary consideration for thrombolytic therapy administration. Option C, size and location of the MI, is also significant for prognosis and further management but does not take precedence over the urgency of timely thrombolytic therapy. Educationally, understanding the critical importance of timely intervention in acute myocardial infarction highlights the need for healthcare providers to rapidly assess and initiate appropriate treatments to minimize cardiac damage and improve patient outcomes. This knowledge underscores the significance of quick decision-making and action in emergency cardiac care.