ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 24 Questions
Question 1 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.
Question 2 of 5
The client has been diagnosed with aortic regurgitation. Which nursing data is most significant in identifying the cause for this disorder?
Correct Answer: C
Rationale: The incidence of mitral and aortic regurgitation increased by as much as 36% in 1997, due to the use of fenfluramine with phentermine (Fen-Phen) for weight loss. Obesity, tobacco use, and lack of exercise have been identified as risk factors for heart disease but not a significant identified cause for aortic regurgitation.
Question 3 of 5
The nurse collects data for a client who is diagnosed with mitral stenosis with a murmur. In which position does the nurse place the client to auscultate the documented murmur?
Correct Answer: C
Rationale: Changes in heart sounds may be the earliest indication of mitral valve stenosis. S1 may be extremely loud if the cusps are fused or muffled or absent if the cusps have calcified and are immobile. A murmur, described as sounding like a rumbling underground train, can be heard at the heart's apex, especially when the client assumes a left lateral position. The other positions are not supported by evidence-based practice guidelines as appropriate positions in which to place the client to monitor a murmur.
Question 4 of 5
A client with aortic valve regurgitation is asking about the disease process. What would the nurse tell the client is the first sign of aortic valve regurgitation?
Correct Answer: A
Rationale: Tachycardia is one of the first signs of cardiac compensation. When valve damage affects the left ventricle, the client becomes aware of forceful heart contractions (palpitations). At first, palpitations occur only when lying flat or on the left side. Aortic valve regurgitation does not produce left-sided heart failure, pain, or dysrhythmias as the first symptom of disease.
Question 5 of 5
A client with mitral stenosis develops a productive cough with pink, frothy sputum. The best interpretation made by the nurse would be to further evaluate for which complication?
Correct Answer: A
Rationale: A cough with productive, pink, frothy sputum and crackles in the bases of the lungs are signs of pulmonary congestion. Pink, frothy sputum would not be present in congestive failure, thrombophlebitis, or cardiogenic shock.