ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 24 Questions
Question 1 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 2 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.
Question 3 of 5
The client is scheduled for a percutaneous balloon valvuloplasty. The client asks the nurse how long it takes for the opening to close after the procedure. How should the nurse respond?
Correct Answer: C
Rationale: The opening usually closes within 6 months of a percutaneous balloon valvuloplasty. It usually takes longer than 1 week or 1 month, but less than 1 year.
Question 4 of 5
The nurse is caring for a client with a valvular disorder of the heart. What intervention should the nurse perform before administering the prescribed beta-blockers to clients with valvular disorders of the heart?
Correct Answer: C
Rationale: Before administering beta-blockers, the nurse should take the client's apical pulse. If the heart rate is less than 60 beats/minute, the nurse should withhold the drug and inform the primary healthcare provider. Oral anticoagulant therapy requires close monitoring of prothrombin time or INR. The nurse should also closely monitor clients receiving oral anticoagulants for episodes of bleeding. Overdosage of beta-blockers indicates bluish discoloration of the palms.
Question 5 of 5
The nurse is caring for a client with a valvular disorder. The client is at risk for decreased cardiac output. What nursing intervention should a nurse perform for this client?
Correct Answer: D
Rationale: The nurse should monitor urine output every 8 hours or more often if it is less than 500 mL/day. Renal output reflects the heart's ability to perfuse the renal arteries. The client should not perform any exercises and should be on bed rest. Keeping the client's legs horizontal and auscultating lung and heart sounds will not help in this condition.