ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 24 : Caring for Clients With Valvular Disorders of the Heart Questions
Question 1 of 5
Before administering digoxin to a client with valvular disease, the nurse assesses the apical heart rate as 62 beats/minute. The client's usual rate ranges between 66 to 72 beats/minute. Which is the best action for the nurse to take?
Correct Answer: C
Rationale: A heart rate of 62 beats/minute falls within the normal range for administration of this drug. Holding the medication would not be recommended unless a specific prescription was detailed to do so. The nurse may decide to recheck the pulse but this is not required. Notifying the physician of normal findings is not efficient use of time or resources.
Question 2 of 5
A client with progressive mitral valve prolapse is experiencing sympathetic nervous system symptoms in addition to prolapse symptoms. Which teaching point should be stressed by the nurse to minimize these effects?
Correct Answer: C
Rationale: The symptoms associated with sympathetic nervous response (anxiety, agitation, nervousness, and palpitations) are often managed with antianxiety medications and advisement to avoid caffeine and over-the-counter medications that contain stimulants. Periodic antibiotic therapy use before an invasive procedure is not associated with sympathetic nervous system symptoms. Low-dose aspirin is used to prevent thrombus formation. Decreasing fluid and sodium intake is indicated for the control of congestive failure.
Question 3 of 5
The nurse is providing teaching to a post-valve replacement client. Which activit(ies) would require prophylactic antibiotic use? Select all that apply.
Correct Answer: B,E
Rationale: Dental cleaning/care and colonoscopy are invasive procedures that can disturb the normal bacteria located in residence and place a valve replacement client at risk for infective endocarditis. Vision screening, echocardiogram, MRI, and chelation therapy are not invasive procedures and do not mobilize bacteria.
Question 4 of 5
When assessing a client, what sign would the nurse know is an early sign of an impending heart failure?
Correct Answer: B
Rationale: An S3 heart sound, if heard, is an early sign of impending heart failure. The S1 heart sound is normal. Heart murmur is not a sign of impending heart failure. Moist lung sounds could be indicative of either heart failure or pneumonia.
Question 5 of 5
The client is complaining of severe dizziness and drowsiness. Upon assessment, the nurse finds the client has bradycardia and a bluish discoloration of the palms and fingernails. What do these signs and symptoms indicate?
Correct Answer: B
Rationale: These signs and symptoms indicate overdosage of a drug. The nurse should inform the care provider immediately if these symptoms appear. These are not the signs and symptoms of cinchonism, hypokalemia, or hypertension.