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 ["2"]
Explanation
Step 1: We need to find out how many mL contain 10 mg of loratadine. Since 5 mg of loratadine is in 5 mL, we can set up a proportion to find out how many mL contain 10 mg.
So, 5 mg is to 5 mL as 10 mg is to X mL.
This gives us the equation: (5 mg ÷ 5 mL) = (10 mg ÷ X mL)
Step 2: Solving for X gives us X = (10 mg × 5 mL) ÷ 5 mg
Step 3: Simplifying gives us X = 10 mL
So, the client needs to take 10 mL of the loratadine suspension to get a dose of 10 mg.
Now, we need to convert this volume in mL to teaspoons, using the conversion factor you provided (1 teaspoon = 5 mL).
Step 4: We set up the conversion as follows: 10 mL × (1 tsp ÷ 5 mL)
Step 5: Simplifying gives us 2 tsp
So, the nurse should instruct the client to take 2 teaspoons of the loratadine suspension.
Correct Answer is C
Explanation
Choice A reason: Advising the client to maintain bedrest may not be practical or beneficial for the client's overall health and does not address the UAP's concern about safe transfer.
Choice B reason: While it is true that all clients deserve equal care, this statement does not provide a solution to the UAP's concern about safely assisting the client.
Choice C reason: Determining the client's level of mobility and need for assistance will help in creating a safe and effective plan for transferring the client to the bedside commode.
Choice D reason: Assigning another UAP may be necessary if the current UAP is unable to assist safely, but it is not the first step. The nurse should first assess the situation before making staffing changes.
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