Answer to Question 1
A
The nurse must continually monitor for clinical manifestations of bleeding. Mild gingival bleeding and oozing around venipuncture sites are common and not causes for concern. However, severe lower back pain and ecchymoses are suggestive of retroperitoneal bleeding. If serious bleeding occurs, all fibrinolytic heparin therapies are discontinued, and volume expanders, coagulation factors, or both are administered.
Answer to Question 2
C
Ventricular septal rupture is a new opening in the septum between the two ventricles. It creates a harsh, holosystolic murmur that is loudest (by auscultation) along the left sternal border. Papillary muscle rupture is auscultation of a new, high-pitched, holosystolic, blowing murmur at the cardiac apex. Tricuspid stenosis is a quiet murmur that becomes louder with inspiration and is located in the epigastrium area. A pericardial friction rub is a sound that can occur within 2 to 7 days after a myocardial infarction. The friction rub results from pericardial inflammation (pericarditis). Classically, a pericardial friction rub is a grating or scratching sound that is both systolic and diastolic, corresponding to cardiac motion within the pericardial sac.
Concept Care Map
Culturally competent care
Patient wearing an abularm
Patient's forearm supported in bed
Fundus of white pateint and black patient
Pneumonia patient’s chest x-ray. Note the irregular areas of density.