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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason : A fixed volume deficit, or hypovolemia, is not a direct finding associated with bradycardia. Bradycardia refers to a slower than normal heart rate, typically below 60 beats per minute in adults⁸. Hypovolemia can cause various compensatory mechanisms to activate, including an increase in heart rate to maintain cardiac output, which is the opposite of bradycardia. Therefore, a fixed volume deficit is not a typical finding in bradycardia unless it is part of a broader clinical picture⁹.
Choice B reason : Anxiety is a condition that can sometimes lead to an increased heart rate, known as tachycardia, rather than a decreased heart rate as seen in bradycardia. While anxiety can coexist with bradycardia, especially if the patient is anxious about their health, it is not a direct symptom or finding of bradycardia itself⁹.
Choice C reason : Lightheadedness is a common symptom of bradycardia. When the heart rate is too slow, it may lead to inadequate cerebral perfusion, which can cause a feeling of lightheadedness or dizziness. This symptom can be particularly evident when the patient changes positions, such as standing up quickly, which can exacerbate the effects of reduced cardiac output on cerebral blood flow⁸⁹.
Choice D reason : An elevated temperature is not typically associated with bradycardia. Fever can actually lead to an increased heart rate as the body attempts to manage the higher metabolic demands associated with a raised temperature. Bradycardia in the presence of fever might indicate a more complex clinical scenario, such as myocarditis or central nervous system infections, but it is not a direct finding of bradycardia⁹.
Correct Answer is B
Explanation
Choice A reason : Probiotics are beneficial for gut health and may have a role in maintaining a healthy immune system, but they are not primarily known for lowering blood pressure. While some studies suggest a potential benefit of probiotics on blood pressure, more research is needed to establish a direct effect.
Choice B reason : Garlic is well-known for its potential benefits in lowering blood pressure. It contains allicin, which is thought to help relax blood vessels and improve blood flow, thereby reducing blood pressure. Studies have shown that garlic supplements can have a significant impact on reducing blood pressure in individuals with hypertension.
Choice C reason : Ginger root is commonly used for its anti-inflammatory properties and gastrointestinal benefits. Some studies suggest that ginger may help lower blood pressure, but the evidence is not as strong as it is for garlic. Therefore, it is not the primary recommendation for hypertension management.
Choice D reason : Valerian is often used for its sedative effects and to aid sleep. There is limited evidence to suggest that valerian has any significant impact on blood pressure. It is not typically recommended as a treatment for hypertension.
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