A client with a diagnosis of valvular heart disease is being considered for mechanical valve replacement. Which circumstance is essential to assess before the surgery is performed?

The ability to comply with anticoagulant therapy for life.

The likelihood of the client experiencing body image problems.

The physical demands of the client’s lifestyle.

The ability to participate in a cardiac rehabilitation program.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The ability to comply with anticoagulant therapy for life is essential for clients undergoing mechanical valve replacement. Mechanical valves are prone to thrombus formation, which can lead to serious complications such as stroke. Therefore, lifelong anticoagulation therapy is necessary to prevent clot formation on the valve.

Choice B rationale

While body image problems may arise due to surgical scars or the presence of a mechanical valve, they are not a primary concern that needs to be assessed before surgery. The focus should be on the client’s ability to manage the medical requirements post-surgery.

Choice C rationale

The physical demands of the client’s lifestyle are important but not as critical as the ability to comply with anticoagulant therapy. The primary concern is ensuring the client can adhere to the necessary medical regimen to prevent complications.

Choice D rationale

Participation in a cardiac rehabilitation program is beneficial for recovery and improving cardiovascular health, but it is not as crucial as the ability to comply with anticoagulant therapy. The main priority is preventing thrombus formation on the mechanical valve.

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Correct Answer is ["A","B","C","E"]

Explanation

Choice A rationale

Providing diversionary activities for the client can help distract them and reduce the likelihood of them pulling on their NG tube. Diversionary activities can include engaging the client in conversation, providing them with puzzles or games, or allowing them to watch television or listen to music. These activities can help occupy the client’s time and attention, reducing the need for restraints.

Choice B rationale

Assisting the client with toileting at frequent intervals can address any discomfort or need that may be causing the client to pull on their NG tube. Ensuring that the client is comfortable and their needs are met can reduce agitation and the likelihood of them pulling on the tube.

Choice C rationale

Involving the family in the client’s care can provide additional support and reassurance to the client. Family members can help calm the client and provide a familiar presence, which can reduce anxiety and the need for restraints.

Choice E rationale

Using an electronic bed alarm device can alert the nursing staff if the client attempts to get out of bed or pull on their NG tube. This allows for timely intervention without the need for physical restraints.

A. Medicate for pain. B. Maintain the airway. C. Insert an indwelling urinary catheter. D. Initiate fluid resuscitation.

Correct Answer is B

Explanation

Choice A rationale

While pain management is important, maintaining the airway is the priority intervention for a client with deep partial- and full-thickness burns to the face, chest, abdomen, and upper arms. Burns to the face and chest can cause airway edema and compromise breathing.

Choice B rationale

Maintaining the airway is the priority intervention during the resuscitation phase of injury for a client with burns to the face, chest, abdomen, and upper arms. Airway edema can develop rapidly, and securing the airway is crucial to ensure adequate oxygenation and ventilation.

Choice C rationale

Inserting an indwelling urinary catheter is important for monitoring urine output and fluid balance, but it is not the priority intervention. Airway management takes precedence in this scenario.

Choice D rationale

Initiating fluid resuscitation is essential for managing burn shock and maintaining hemodynamic stability, but maintaining the airway is the priority intervention to ensure the client can breathe adequately.

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A client with a diagnosis of valvular heart disease is being considered for mechanical valve replacement. Which circumstance is essential to assess before the surgery is performed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his face, chest, abdomen, and upper arms. What is the nurse’s priority intervention for this client during the resuscitation phase of injury?

Correct Answer is B

Explanation

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