A nurse is collecting data on a client who has mitral valve stenosis. Which of the following findings should the nurse expect?
Heart murmur
Bradycardia
Clubbing of the fingers
Barrel chest
The Correct Answer is A
Choice A reason: A heart murmur is a common finding in clients who have mitral valve stenosis. It is a sound produced by turbulent blood flow through the narrowed valve. The murmur is usually heard as a low-pitched rumbling sound during diastole.
Choice B reason: Bradycardia is not a typical finding in clients who have mitral valve stenosis. Bradycardia is a slow heart rate, usually below 60 beats per minute. Mitral valve stenosis can cause tachycardia, which is a fast heart rate, due to increased cardiac workload and reduced cardiac output.
Choice C reason: Clubbing of the fingers is not a sign of mitral valve stenosis. Clubbing is a deformity of the fingertips and nails that occurs due to chronic hypoxia. Mitral valve stenosis can cause pulmonary hypertension and pulmonary edema, which can impair gas exchange, but not to the extent of causing clubbing.
Choice D reason: Barrel chest is not a sign of mitral valve stenosis. Barrel chest is a condition where the chest is enlarged and rounded due to chronic lung disease. Mitral valve stenosis can affect the lungs by increasing the pressure in the pulmonary circulation, but it does not cause structural changes in the chest wall.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Requesting that the provider prescribe a stool softener is not the best action for the nurse to take, as it may cause dependency, dehydration, or electrolyte imbalance. The nurse should try non-pharmacological interventions first, such as increasing fluid and fiber intake, promoting physical activity, and establishing a regular bowel routine.
Choice B reason: Adding fluid and fiber to the diet is the best action for the nurse to take, as it helps to soften the stool, increase the bulk, and stimulate peristalsis. The nurse should encourage the client to drink at least 2 liters of water per day and eat foods rich in fiber, such as fruits, vegetables, and whole grains.
Choice C reason: Promoting active range-of-motion activities is a good action for the nurse to take, as it helps to improve circulation, muscle tone, and bowel motility. The nurse should assist the client to perform exercises that are appropriate for their level of mobility and endurance.
Choice D reason: Avoiding gas-producing foods is not a necessary action for the nurse to take, as it does not directly affect constipation. Gas-producing foods, such as beans, cabbage, and broccoli, may cause bloating and discomfort, but they do not cause or worsen constipation.
Correct Answer is A
Explanation
The correct answer is: A. Place the client on continuous cardiac monitoring.
Choice A reason:
Placing the client on continuous cardiac monitoring is crucial because metabolic alkalosis can lead to life-threatening arrhythmias due to electrolyte imbalances, particularly hypokalemia. Continuous monitoring allows for the early detection and management of these arrhythmias, ensuring patient safety.
Choice B reason:
Obtaining a prescription for insulin is not relevant for treating metabolic alkalosis. Insulin is typically used for managing hyperglycemia and diabetic ketoacidosis, not for correcting alkalosis.
Choice C reason:
Planning to administer sodium bicarbonate is incorrect because sodium bicarbonate is used to treat metabolic acidosis, not alkalosis. Administering it in this context could worsen the alkalosis.
Choice D reason:
Having the client breathe into a paper bag is a technique used for respiratory alkalosis to increase CO2 levels. It is not appropriate for metabolic alkalosis, which requires different management strategies.
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