A nurse is collecting data on a patient who is postoperative following aortic valve replacement. Which of the following tasks should the nurse prioritize during data collection?

Check the level of the client's pain.

Check the client's blood pressure.

Check the client's bowel sounds.

Check the client's catheter insertion site.

Answer and Explanation

The Correct Answer is A

Choice A reason: Pain assessment is a critical priority for postoperative patients. After aortic valve replacement surgery, patients may experience discomfort or pain related to the incision site, chest tube placement, or other surgical interventions. Pain assessment allows the nurse to evaluate the effectiveness of pain management strategies, adjust medications as needed, and ensure the patient's comfort and well-being. Pain can also impact vital signs and overall recovery, so addressing it promptly is essential.

Choice B reason: Monitoring blood pressure is important, but it is not the highest priority immediately after surgery. Blood pressure assessment is part of routine postoperative care, but it does not directly address the patient's immediate comfort or potential complications. However, if the patient's blood pressure becomes significantly abnormal, it would require immediate attention.

Choice C reason: Checking bowel sounds is relevant for assessing gastrointestinal function, but it is not the top priority immediately postoperatively. Bowel sounds may be diminished initially due to anesthesia, surgical manipulation, or bowel rest. However, assessing pain and other vital signs takes precedence over bowel sounds in the immediate recovery period.

Choice D reason: Assessing the catheter insertion site is essential, especially if the patient has an indwelling urinary catheter. However, it is not the highest priority immediately after aortic valve replacement. Pain assessment and monitoring for complications related to surgery (such as bleeding, infection, or cardiac issues) take precedence. The catheter site can be assessed during routine nursing care.

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Free Nursing Study Resources

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.

A. Barrel chest B. Clubbing of the fingers C. Heart murmur D. Bradycardia

Correct Answer is C

Explanation

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.

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A nurse is collecting data on a patient who is postoperative following aortic valve replacement. Which of the following tasks should the nurse prioritize during data collection?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["50"]

Explanation

A nurse is collecting data on a patient who has mitral valve stenosis. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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