A nurse is assessing a patient who has mitral valve stenosis.
What symptoms should the nurse expect?

Heart murmur

Bradycardia

Clubbing of the fingers

Barrel chest

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Mitral valve stenosis is a condition characterized by a narrowing of the mitral valve in the heart, which can lead to a variety of symptoms. One of the most common symptoms of mitral valve stenosis is a heart murmur. This is due to the turbulent flow of blood caused by the narrowed valve. The murmur is typically heard during a physical examination when a healthcare provider listens to the heart with a stethoscope.

Choice B rationale:

Bradycardia, or a slower than normal heart rate, is not typically associated with mitral valve stenosis. While mitral valve stenosis can cause irregular heart rhythms, it does not typically cause the heart rate to slow down.

Choice C rationale:

Clubbing of the fingers is a physical symptom that involves changes in the areas under and around the nails and is typically associated with conditions that cause chronic low blood oxygen levels. While mitral valve stenosis can lead to shortness of breath and fatigue, it does not typically cause clubbing of the fingers.

Choice D rationale:

A barrel chest, characterized by an increased chest diameter, is typically associated with conditions that cause chronic overinflation of the lungs, such as chronic obstructive pulmonary disease (COPD). It is not a typical symptom of mitral valve stenosis.

In conclusion, while mitral valve stenosis can lead to a variety of symptoms, the most relevant to this question is a heart murmur. Other symptoms such as bradycardia, clubbing of the fingers, and a barrel chest are not typically associated with this condition.

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Correct Answer is B

Explanation

Choice A rationale:

Positioning the client supine is not the immediate next step after performing hand hygiene when preparing to remove a patient’s urinary catheter. While it is important to ensure the patient is in a comfortable and appropriate position for the procedure, the immediate next step should be focused on ensuring the area is clean to prevent infection.

Choice B rationale:

After performing hand hygiene, the nurse should cleanse the perineal area with an antiseptic. This is to ensure that the area is clean before proceeding with the removal of the urinary catheter. It helps to prevent the introduction of bacteria into the urinary tract, which could lead to a urinary tract infection. The use of an antiseptic is recommended to kill any potential pathogens that may be present.

Choice C rationale:

Deflating the balloon halfway and then pulling out the catheter is not the immediate next step after performing hand hygiene. This step is usually done later in the process. Before deflating the balloon, it is important to ensure that the area is clean to prevent infection. Moreover, deflating the balloon halfway could potentially cause discomfort or injury to the patient. The balloon should be fully deflated before the catheter is removed.

Choice D rationale:

Having the client bear down during removal is not the immediate next step after performing hand hygiene. This action might be suggested during the actual removal of the catheter to aid in the process, but it is not the immediate next step. The focus right after hand hygiene should be on cleaning the area to prevent infection.

A. The AP assists the patient to the bathroom every 2 hours. B. The AP offers the patient the opportunity to urinate 15 minutes before bathing. C. The AP instructs the patient to urinate whenever they feel the urge.

Correct Answer is A

Explanation

The correct answer is choice A.

Choice A rationale: Assisting the patient to the bathroom every 2 hours is a fixed schedule that doesn't allow for individual variations in bladder function. A bladder-training program should encourage the patient to recognize and respond to their own urge to urinate, promoting self-reliance and bladder control.

Choice B rationale: Offering the opportunity to urinate before bathing is a good practice to prevent accidents and promote comfort. It also helps to reduce the risk of urinary tract infections.

Choice C rationale: Encouraging the patient to urinate when they feel the urge is a key component of bladder training. It helps the patient to develop bladder control and reduce the frequency of accidents.

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A nurse is assessing a patient who has mitral valve stenosis. What symptoms should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to remove a patient’s urinary catheter. After performing hand hygiene, what should the nurse do next?

Correct Answer is B

Explanation

A nurse is implementing a bladder-training program for a patient. Which of the following actions by the assistive personnel (AP) assisting with the patient’s care should the nurse intervene?

Correct Answer is A

Explanation

A nurse is collecting data on a patient who is experiencing oxygen toxicity. What symptoms should the nurse anticipate?

A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. Which of the following findings should the nurse identify as an indication of an adverse effect of oxygen therapy?

A nurse is educating a patient about food and drinks that can trigger diarrhea. Which items should the nurse include in the teaching?

A nurse is caring for a patient who is experiencing nausea and vomiting. The nurse should identify that the patient is at risk for which of the following acid-base imbalances?

A nurse is assisting with the care of a client who has respiratory alkalosis and is hyperventilating. What action should the nurse take?

A nurse is helping to implement a bowel training program for a patient. To ensure the effectiveness of the program, when should the nurse take the patient to the bathroom?

A nurse is in the process of collecting a urine specimen for culture and sensitivity through straight catheterization. Which step should the nurse take in this procedure?

A nurse is gathering data on a patient who has diarrhea. Which of the following findings is a sign of hypokalemia?

A nurse is assessing a patient who has mitral valve stenosis.
What symptoms should the nurse expect?