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The presence of an S3 gallop is noted in a client. What should the nurse do?
- A. Assess for symptoms of left-sided heart failure
- B. Document this as a normal finding
- C. Call the health care provider immediately
- D. Transfer the client to the intensive care unit
Correct Answer: A
Rationale: The presence of an S3 gallop is an early diastolic filling sound indicative of increasing left ventricular pressure and left ventricular failure. The other actions are not warranted.
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A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the priority nursing intervention?
- A. Oxygen saturation of 90%
- B. Dyspnea on exertion
- C. Mild systolic murmurs
- D. Upper extremity weakness
Correct Answer: B
Rationale: Dyspnea on exertion develops as the mitral valvular orifice narrows and pressure in the lungs increases. The other manifestations do not directly indicate the progression of mitral valve stenosis.
A nurse assesses a client for signs of infective endocarditis. Which clinical manifestations should the nurse expect?
- A. Weight gain
- B. Night sweats
- C. Cardiac murmur
- D. Abdominal bloating
- E. Osler nodes
Correct Answer: B,C,E
Rationale: Clinical manifestations of infective endocarditis include night sweats, cardiac murmur, and Osler nodes. Weight gain and abdominal bloating are not typical; the latter is associated with heart transplant rejection.
A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, 'Why will I need to take anticoagulants for the rest of my life?' How should the nurse respond?
- A. The prosthetic valve requires thinner blood to function properly
- B. Blood clots form more easily in artificial replacement valves
- C. The vein taken from your leg reduces circulation in the leg
- D. The surgery left a lot of small clots in your heart and lungs
Correct Answer: B
Rationale: Synthetic valve prostheses and scar tissue provide surfaces on which platelets can aggregate easily and initiate the formation of blood clots. The other responses are inaccurate.
A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include for this client's discharge teaching?
- A. Use a soft-bristled toothbrush and avoid flossing
- B. Avoid large crowds and people who are sick
- C. Monitor your heart rate before taking the medication
- D. Take the medication with a high-fat meal
Correct Answer: B
Rationale: Cyclosporine causes immune suppression, leaving the client more vulnerable to infection. Avoiding large crowds and sick people reduces infection risk. The medication does not increase bleeding risk, affect heart rate, or require a high-fat meal.
A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take?
- A. Initiate oxygen therapy
- B. Hold the next dose of Imdur
- C. Instruct the client to drink water
- D. Administer PRN acetaminophen
Correct Answer: D
Rationale: The vasodilating effects of isosorbide mononitrate frequently cause headaches during the initial period of therapy. Clients should be told about this side effect and encouraged to take the medication with food. Some clients obtain relief with mild analgesics, such as acetaminophen. The headache is not related to hypoxia or dehydration, so oxygen or water would not help. Holding the medication is not warranted.