valvular disease med surg 1
d,e
A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.) a: Administer pain medication (BP is too low for pain meds). b: Assess distal pulses every 10 minutes. c: Have the client sign a surgical consent. d: Notify the Rapid Response Team. e: Take vital signs every 10 minutes.
b
A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess? a: Premature ventricular contractions b: Atrial fibrillation c: Symptomatic bradycardia d: Sinus tachycardia
b
A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the client's stenosis has progressed? a: Oxygen saturation of 92% b: Dyspnea on exertion c: Muted systolic murmur d: Upper extremity weakness
b
A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find? a: Heart rate that speeds up and slows down b: Friction rub at the left lower sternal border c: Presence of a regular gallop rhythm d: Coarse crackles in bilateral lung bases
b
A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why will I need to take anticoagulants for the rest of my life?" How should the nurse respond? a: "The prosthetic valve places you at greater risk for a heart attack." b: "Blood clots form more easily in artificial replacement valves." c: "The vein taken from your leg reduces circulation in the leg." d: "The surgery left a lot of small clots in your heart and lungs."
a
A nurse is care for a patient who has undergone surgical repair of an abdominal aortic aneurysm (AAA). The patient develops coolness of the extremities and reports a bloated feeling in the abdomen. What is the nurse's best action? A. Check for abdominal distention and check pulses. B. Raise the head of the bed to 90 degrees C. Assess urine output D. Auscultate the abdomen
d
A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which non-pharmacologic comfort measure should the nurse implement? a: Apply an ice pack to the client's chest. b: Provide a neck rub, especially on the left side. c: Allow the client to lie in bed with the lights down. d: Sit the client up with a pillow to lean forward on.
d
A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene? a:Assesses the client for back pain b:Auscultates over abdominal bruit c:Measures the abdominal girth d: Palpates the abdomen abdominal mass
d
A patient who recently had a valve replacement is taking warfarin (Coumadin) as prescribed. What health teaching will the nurse include before the patient is discharged? A. "Weigh yourself every day in the morning using the same scale." B. "Purchase a home kit to monitor your blood pressure every day." C. "You must take your pulse every day before taking this medication." D. "Avoid foods that are high in vitamin K, such as kale and spinach."
b
A patient with a previously diagnosed abdominal aortic aneurysm (AAA) develops lower back pain that is sharp and tearing. What is the nurse's interpretation of this assessment finding? A. The aneurysm clotted and is obstructing blood flow. B. The aneurysm has ruptured. C. The patient feels the inflammation of the aneurysm D. This is a normal sensation with a stable AAA.
b
After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the client's understanding. Which client statement indicates a need for additional teaching? a: "I'll be able to carry heavy loads after 6 months of rest." b: "I will have my teeth cleaned by my dentist in 2 weeks." Risk for endocarditis c: "I must avoid eating foods high in vitamin K, like spinach." d: "I must use an electric razor instead of a straight razor to shave."
d
Mr. Jones is diagnosed with a 1.5mm abdominal aortic aneurysm (AAA). Part of the overall plan for Mr. Jones will include: A. Discussion of the diagnostic test. B. Evaluation of the non-modifiable risk factors that Mr. Jones has. C. Scheduling for further testing. D. Management of Mr. Jones's blood pressure to prevent expansion and rupture of the AAA.
c
the nurse is providing discharge education to a patient after repair of an abdominal aortic aneurysm (AAA). What priority instruction does the nurse include? A. "No restrictions are necessary." B. "Avoid sleeping on your left side for 6 weeks." C. "Avoid heavy lifting for about 3 months." D. "You will have a distended abdomen for 2 weeks."
