Nokea
The nurse collects data for a client who is diagnosed with mitral stenosis with a murmur. In which position does the nurse place the client to auscultate the documented murmur?
- A. Prone
- B. Supine
- C. Left lateral
- D. Right lateral
Correct Answer: C
Rationale: Changes in heart sounds may be the earliest indication of mitral valve stenosis. S1 may be extremely loud if the cusps are fused or muffled or absent if the cusps have calcified and are immobile. A murmur, described as sounding like a rumbling underground train, can be heard at the heart's apex, especially when the client assumes a left lateral position. The other positions are not supported by evidence-based practice guidelines as appropriate positions in which to place the client to monitor a murmur.
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When assessing a client, what sign would the nurse know is an early sign of an impending heart failure?
- A. S1 heart sound
- B. S3 heart sound
- C. Heart murmur
- D. Crackles
Correct Answer: B
Rationale: An S3 heart sound, if heard, is an early sign of impending heart failure. The S1 heart sound is normal. Heart murmur is not a sign of impending heart failure. Moist lung sounds could be indicative of either heart failure or pneumonia.
A client reports a family history of aortic stenosis. Which assessment finding would the nurse identify as a likely contributing factor?
- A. High blood pressure
- B. Missing aortic cusp
- C. Unidirectional blood flow
- D. Chest pain
Correct Answer: B
Rationale: In young adults, aortic stenosis usually is a consequence of a congenital defect in which the valve has two instead of three cusps. High blood pressure and chest pain are symptoms that can be exhibited in aortic stenosis. Unidirectional blood flow is the normal flow of blood through the heart.
The nurse is providing teaching to a post-valve replacement client. Which activit(ies) would require prophylactic antibiotic use? Select all that apply.
- A. Vision screening
- B. Dental care
- C. Echocardiogram
- D. MRI
- E. Colonoscopy
- F. Chelation therapy
Correct Answer: B,E
Rationale: Dental cleaning/care and colonoscopy are invasive procedures that can disturb the normal bacteria located in residence and place a valve replacement client at risk for infective endocarditis. Vision screening, echocardiogram, MRI, and chelation therapy are not invasive procedures and do not mobilize bacteria.
What must the nurse assess for to determine adequate care for a client with aortic stenosis?
- A. Increased systolic pressure
- B. Calcification of aortic valve
- C. Angina
- D. Systolic murmur
Correct Answer: C
Rationale: Angina indicates insufficient nourishment of the myocardium, which can increase the risk for mortality. The systolic blood pressure increases to force blood through the narrowed opening, and systolic murmurs can be identified in some clients, but are not the most important factors. Calcification of the aortic valve is a cause for the disorder.
Before administering digoxin to a client with valvular disease, the nurse assesses the apical heart rate as 62 beats/minute. The client's usual rate ranges between 66 to 72 beats/minute. Which is the best action for the nurse to take?
- A. Hold the digoxin.
- B. Recheck the apical pulse in 30 minutes.
- C. Administer the digoxin.
- D. Notify the physician.
Correct Answer: C
Rationale: A heart rate of 62 beats/minute falls within the normal range for administration of this drug. Holding the medication would not be recommended unless a specific prescription was detailed to do so. The nurse may decide to recheck the pulse but this is not required. Notifying the physician of normal findings is not efficient use of time or resources.