A client with a history of rheumatic fever is diagnosed with mitral valve stenosis. The client has shortness of breath with exertion and fatigue. Which assessment finding warrants immediate intervention by the nurse?
Elevated blood pressure.
Rapid, irregular heart rate.
Swollen feet and ankles.
Blood-tinged sputum.
The Correct Answer is D
Choice A reason: Elevated blood pressure is a concern but not as immediately threatening as some other symptoms associated with mitral valve stenosis.
Choice B reason: A rapid, irregular heart rate could indicate atrial fibrillation, which is common in mitral valve stenosis, but it is not as urgent as blood-tinged sputum.
Choice C reason: Swollen feet and ankles suggest fluid retention, which is a concern in mitral valve stenosis but not as immediate as hemoptysis.
Choice D reason: Blood-tinged sputum indicates hemoptysis, which can be a sign of pulmonary edema or other serious complications requiring immediate intervention. This symptom is the most urgent and could signify a potentially life-threatening condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Massaging the back to promote diaphragmatic excursion can be beneficial but is not the most effective intervention compared to early mobilization.
Choice B reason: Assisting the client to sit in a chair encourages lung expansion and sputum clearance, which are crucial for preventing atelectasis and pneumonia.
Choice C reason: Noting areas of atelectasis on chest x-rays is important for monitoring, but it is not an intervention that actively prevents respiratory complications.
Choice D reason: Providing ice or oral liquids when the client passes flatus is related to gastrointestinal recovery, not respiratory complications.
Correct Answer is B
Explanation
Choice A reason: While it's important to know if the client can lie prone, this is not the most critical piece of information prior to an intravenous pyelogram.
Choice B reason: Asking about a shellfish allergy is crucial because the contrast dye used in an intravenous pyelogram may contain iodine, which can cause an allergic reaction in individuals with shellfish allergies.
Choice C reason: Knowing the last time the client had a bowel movement is less critical than knowing about potential allergies to the contrast dye.
Choice D reason: While it's important to know about medication schedules, the risk of an allergic reaction to the contrast dye is a more immediate concern that could affect the safety of the procedure.
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