A nurse is collecting data on a patient who has mitral valve stenosis. Which of the following findings should the nurse expect?
Barrel chest
Clubbing of the fingers
Heart murmur
Bradycardia
The Correct Answer is C
Choice A reason: A barrel chest is typically not associated with mitral valve stenosis. It is more commonly seen in chronic obstructive pulmonary disease (COPD) due to hyperinflation of the lungs. Mitral valve stenosis affects the heart and not the lung structure.
Choice B reason: Clubbing of the fingers is a sign that can be associated with chronic hypoxia and certain types of congenital heart disease. While it can be seen in some heart conditions, it is not a specific finding for mitral valve stenosis.
Choice C reason: A heart murmur, specifically a diastolic murmur, is a classic finding in mitral valve stenosis. As the stenotic mitral valve obstructs blood flow from the left atrium to the left ventricle, a pressure gradient is created, which produces a murmur that can be heard upon auscultation.
Choice D reason: Bradycardia, or a slower than normal heart rate, is not a direct finding associated with mitral valve stenosis. Mitral valve stenosis may lead to arrhythmias such as atrial fibrillation due to atrial enlargement, but bradycardia is not typically induced by this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["50"]
Explanation
Step 1 is to calculate the total drops (gtt) the nurse needs to administer. This is done by multiplying the volume of the solution (400 mL) by the drop factor (60 gtt/mL). So, 400 mL × 60 gtt/mL = 24000 gtt.
Step 2 is to calculate the total time in minutes over which the IV should be administered. Since there are 60 minutes in an hour, 8 hours is equivalent to 8 hours × 60 min/hour = 480 minutes.
Step 3 is to calculate the rate at which the IV should be administered. This is done by dividing the total drops by the total time. So, 24000 gtt ÷ 480 min = 50 gtt/min.
The nurse should set the manual IV infusion to deliver approximately 50 gtt/min.
Correct Answer is C
Explanation
Choice A reason : A low sodium diet is often prescribed for patients with heart conditions to help manage blood pressure and fluid retention. It is not typically something that would need to be questioned in the context of recent pacemaker surgery.
Choice B reason : Checking serum cardiac enzyme levels is a common practice after heart surgery to monitor for any signs of damage to the heart muscle. This would not typically be questioned unless there were specific contraindications for the patient.
Choice C reason : An MRI of the chest should be questioned because MRI machines use strong magnetic fields that can interfere with the functioning of a pacemaker. Unless the pacemaker is specifically labeled as MRI-safe, this type of imaging could be dangerous for the patient.
Choice D reason : Physical therapy is a standard part of recovery after many types of surgery, including pacemaker insertion, to help the patient regain strength and mobility. It would not typically be questioned unless the patient had specific restrictions.
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