NCLEX-RN
Immunity NCLEX Questions Questions
Extract:
The following scenario applies to the next 6 items
The nurse in the intensive care unit (ICU) is caring for a 59-year-old female client
Item 4 of 6
Admission Note
Nurses' Notes
Physician Orders
1450 - Client was admitted directly from the primary health care physician's office for a severe exacerbation of systemic lupus erythematosus (SLE). The client was being treated outpatient with corticosteroids but was not responding. Reported intermittent chest pain at the physician's office and became pale and
Diaphoretic. The 12-lead electrocardiogram (ECG) showed normal sinus rhythm with no ST-elevations. Point of care (POC) troponin showed no elevations.
• The client was directly admitted to the intensive care unit for observation and medical management. • Cardiac consultation has been placed, and laboratory work is pending. The client has a medical history of systemic lupus erythematosus (SLE), dyslipidemia, and pulmonary hypertension
Question 1 of 5
For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client experiencing cardiac tamponade.
| Potential Interventions | Indicated | Not Indicated |
|---|---|---|
| Prepare the client for an immediate thoracentesis | ||
| Obtain a prescription for an isotonic fluid bolus | ||
| Perform frequent vital sign collection | ||
| Obtain a prescription for intravenous furosemide |
Correct Answer: C
Rationale: For cardiac tamponade, frequent vital sign collection (
C) is indicated to monitor hemodynamic stability. Thoracentesis (
A) is for pleural effusion, not pericardial fluid. Fluid bolus (
B) may worsen tamponade by increasing pericardial pressure. Furosemide (
D) is contraindicated as it reduces preload, which is already compromised.
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Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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