Question 1

The nurse is teaching a patient about mitral valve prolapse and lifestyle modifications. Which statement made by the patient indicates a need for further teaching?

Accepted Answer

Avoiding physical activity is not generally recommended for patients with mitral valve prolapse. Instead, regular, moderate exercise is often encouraged to maintain cardiovascular health, unless otherwise advised by a healthcare provider.

Question 2

The nurse is caring for a patient with infective endocarditis (IE). Which statement made by the patient leads the nurse to suspect the cause of the IE?

Accepted Answer

Poor dental hygiene or infrequent dental visits can lead to oral infections, which are a common source of bacteria that can cause infective endocarditis.

Question 3

The nurse is reviewing care for a group of patients. Which patient with a heart valve disorder should the nurse identify as being susceptible to developing the complication of fluid volume excess?

Accepted Answer

The 68-year-old female on digoxin (Lanoxin) is most susceptible to developing fluid volume excess. Digoxin is used to treat heart conditions, including heart failure and atrial fibrillation, by increasing the force of cardiac contractions and slowing the heart rate. Patients with heart valve disorders taking digoxin may be at risk for fluid volume excess if their heart function does not adequately compensate, leading to fluid accumulation and edema.

Question 4

The nurse is reinforcing teaching for a patient who has had a mechanical valve replacement. What should be included regarding safety during warfarin (Coumadin) therapy?

Accepted Answer

Patients on warfarin should wear medical alert identification to inform healthcare providers of their anticoagulant use in case of emergencies.

Question 5

The nurse is caring for a patient receiving heparin for thrombophlebitis. The nurse observes the patient has bleeding gums and black tarry stools. Which prescribed medication should the nurse plan to administer?

Accepted Answer

Protamine sulfate is the antidote for heparin overdose, which is indicated by symptoms of bleeding such as bleeding gums and black tarry stools. Vitamin K is the antidote for warfarin, Naloxone for opioids, and Flumazenil for benzodiazepines.

Question 6

The nurse is collecting data on a patient recovering from a hysterectomy who is experiencing left calf tenderness. Data include the following: left calf 17.5 inches; right calf 14 inches; left thigh 32 inches; right thigh 28 inches; shiny, warm, and reddened left leg. Which actions should the nurse recommend for this patient's plan of care?

Accepted Answer

The symptoms and measurements suggest a possible deep vein thrombosis (DVT) in the left leg. Maintaining bedrest is recommended to prevent dislodging a clot, which could lead to a pulmonary embolism.

Question 7

The nurse is caring for a group of patients. Which patient is at highest risk for developing deep vein thrombosis (DVT)?

Accepted Answer

A truck driver is at highest risk for developing deep vein thrombosis (DVT) due to prolonged periods of sitting, which can lead to decreased circulation and increased risk for clot formation.

Question 8

The nurse is caring for a patient with pericarditis who develops hypotension, confusion, tachycardia, tachypnea, and jugular venous distension. For which procedure should the nurse prepare the patient?

Accepted Answer

The patient's symptoms suggest cardiac tamponade, a complication of pericarditis where fluid accumulates in the pericardial sac, compressing the heart and impairing its function. Pericardiocentesis, the removal of fluid from the pericardial sac, is the appropriate procedure to relieve this condition.

Question 9

The nurse is caring for a group of patients. Which patient is at highest risk for developing pericarditis?

Accepted Answer

Patients with renal disease and systemic lupus erythematosus (SLE) are at the highest risk for developing pericarditis due to the systemic inflammation and autoimmunity associated with SLE, which can affect various organs including the pericardium.

Question 10

The nurse is evaluating care provided to a patient with the nursing diagnosis of activity intolerance because of aortic regurgitation. Which outcome indicates that care has been effective?

Accepted Answer

Engaging in desired daily and social activities indicates that the patient has improved their tolerance for activity, which is the goal for someone with a diagnosis of activity intolerance due to aortic regurgitation. This outcome shows that the patient is able to participate more fully in life, which is a positive indicator of effective care.

Question 11

A patient with mitral stenosis is prescribed a preoperative antibiotic. Which patient statement indicates an understanding for taking this medication?

Accepted Answer

Patients with mitral stenosis are at increased risk for developing infective endocarditis, a bacterial infection of the heart's inner lining. Preoperative antibiotics are prescribed to prevent this specific type of infection, especially before surgeries or procedures that could introduce bacteria into the bloodstream.

Question 12

The nurse is caring for a patient who has aortic stenosis. During data collection, which of these manifestations should indicate to the nurse that the patient is experiencing myocardial oxygen deficiency?

Accepted Answer

Angina is a symptom of myocardial oxygen deficiency, which can occur in patients with aortic stenosis due to the heart having to work harder to pump blood through the narrowed valve, leading to decreased oxygen supply to the heart muscle.

Question 13

The nurse is reinforcing teaching about dilated cardiomyopathy. Which statement made by the patient indicates a need for further teaching?

Accepted Answer

Dilated cardiomyopathy often requires treatment to manage symptoms and prevent complications, such as heart failure. Saying treatment is not useful indicates a misunderstanding.

Question 14

The nurse is caring for a group of patients on the cardiac unit. Which patient is at highest risk for mitral valve prolapse?

Accepted Answer

Mitral valve prolapse is more common in females and often diagnosed in young adults, making the 18-year-old female the patient at highest risk.

Question 15

The nurse is assessing a patient who underwent valve replacement surgery. Which finding should concern the nurse the most?

Accepted Answer

Wet lung sounds can indicate pulmonary edema or heart failure, both of which are serious complications after valve replacement surgery. Urine output of 50 mL/hr, a temperature of 99.1°F, and chest tube drainage of 100 mL/hr are within normal or acceptable ranges post-surgery, but wet lung sounds require immediate attention.

Question 16

The nurse is caring for a patient who develops a fever and reports right calf pain with a reddened and swollen calf. Which action should the nurse take?

Accepted Answer

Measuring bilateral calf circumference daily is the correct action because it helps in monitoring the progression of the swelling and assessing for signs of deep vein thrombosis (DVT), which the symptoms suggest. Massaging the affected calf, placing ice, or using elastic stockings without a proper diagnosis could potentially worsen the condition if it is indeed a DVT.

Question 17

The nurse is caring for a patient with aortic regurgitation. Which interventions should the nurse implement?

Accepted Answer

Scheduling activities with periods of rest helps to reduce the workload on the heart and prevent fatigue.

Question 18

The nurse is providing discharge teaching for a patient with mitral stenosis. What should the nurse include in this teaching?

Accepted Answer

Mitral stenosis leads to a narrowing of the mitral valve, which can cause blood flow through the heart to slow down, increasing the risk of blood pooling and clot formation.

Question 19

The nurse is monitoring a patient with aortic stenosis and notes crackles in the lungs and a cough. Which complication should the nurse suspect is occurring in this patient?

Accepted Answer

The symptoms of crackles in the lungs and a cough in a patient with aortic stenosis suggest the development of heart failure. Aortic stenosis can lead to increased pressure in the left ventricle and eventually cause fluid to back up into the lungs, manifesting as crackles and cough due to pulmonary congestion.

Question 20

A patient who has aortic stenosis develops severe dyspnea and chest pain. Which action should the nurse take?

Accepted Answer

The nurse should first obtain vital signs to assess the patient's current status and determine the severity of the situation before proceeding with other interventions.

Quiz 23: Nursing Care of Patients With Valvular, Inflammatory, and Infectious Cardiac or Venous Disorders