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.

Answer and Explanation

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.

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Correct Answer is ["2.4"]

Explanation

Step 1: Convert the weight from pounds to kilograms. We know that 1 kg = 2.2 lbs. So, the weight in kg is:

175 lbs ÷ 2.2 = 79.55 kg

Step 2: Calculate the total units of heparin needed. The prescription is for 3 units/kg, so:

3 units/kg × 79.55 kg = 238.65 units

Step 3: Calculate the volume of heparin to administer. The vial is labeled as "100 units/mL", so:

238.65 units ÷ 100 units/mL = 2.39 mL

So, the nurse should administer approximately 2.4 mL of heparin (rounded to the nearest tenth).

A. Shaking that changes the child's handwriting legibility. B. Thirst and frequent requests for bathroom breaks. C. Refusal to complete written homework assignments. D. Bruises on both knees after the weekend. E. Sunburn with blisters on the face, arms, and hands.

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

Explanation

Choice A reason: Shaking that affects a child's handwriting could indicate a neurological issue or other medical conditions that require immediate attention. It's essential for teachers to report such observations to the school nurse for proper assessment and intervention.

Choice B reason: Excessive thirst and frequent urination can be signs of diabetes, especially in children. Early detection and management are crucial for the child's health, making it important for teachers to report these symptoms.

Choice C reason: While refusal to complete homework could be related to behavioral or social issues, it is not typically a medical concern that requires the school nurse's intervention unless accompanied by other signs of distress or health problems.

Choice D reason: Bruises could be common in children due to their active nature, especially after a weekend. However, unless there is a pattern or other concerning signs of abuse or a medical condition, bruises alone may not necessitate a referral to the school nurse.

Choice E reason: Sunburn with blisters is a sign of a second-degree burn, which can be serious, especially in children. It is important for teachers to report this to the school nurse so that the child can receive proper care and parents can be advised on treatment and prevention.

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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?

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Naxlex Comprehensive Predictor Exams

The healthcare provider has prescribed heparin, 3 units/kg to be administered via IV push for a client who weighs 175 pounds. The vial is labeled as "100 units/mL." How many mL should the nurse administer? (Please enter the numerical value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["2.4"]

Explanation

The school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situation(s) to the school nurse? Select all that apply.

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

Explanation

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