A client is being admitted to the medical unit to rule out cardiac issues related to valve malfunction. Which question should the nurse ask the client during the admission interview to support this diagnosis?

“Did you have rheumatic fever as a child?”

“Do you have a family history of valve problems?”

“Do you have a history of MRSA?”

“What over-the-counter medications do you take?”

Answer and Explanation

The Correct Answer is A

A. "Did you have rheumatic fever as a child?"

Rheumatic fever is an inflammatory condition that can affect the heart, especially the heart valves. Rheumatic fever is a known risk factor for the development of valvular heart disease. Asking about a history of rheumatic fever helps identify a potential cause for valve malfunction.

B. "Do you have a family history of valve problems?"

Family history can be relevant in understanding genetic predispositions to certain cardiac conditions. While it may contribute to the overall assessment of cardiac risk, it may not be as directly linked to valve malfunction as a history of rheumatic fever.

C. "Do you have a history of MRSA?"

MRSA (Methicillin-resistant Staphylococcus aureus) is a type of bacterial infection and is not directly associated with valve malfunction. This question may be relevant for other aspects of the client's health but is not specific to ruling out cardiac issues related to valve malfunction.

D. "What over-the-counter medications do you take?"

While knowing the medications a client takes is important for a comprehensive assessment, asking about over-the-counter medications may not be as directly related to ruling out cardiac issues related to valve malfunction. It is more relevant for assessing potential interactions or effects on cardiovascular health.

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Correct Answer is D

Explanation

A. Lie in a low Fowler’s or supine position:

Lying in a low Fowler's or supine position may worsen respiratory distress and compromise oxygenation. It can reduce lung expansion and increase the work of breathing, especially in patients with pneumonia. This is not a recommended position for individuals with respiratory issues.

B. Increase oral fluids unless contraindicated:

Increasing oral fluids is generally a good practice, especially in respiratory conditions like pneumonia. It helps thin respiratory secretions, making them easier to clear. However, this alone may not address copious tracheobronchial secretions. Suctioning may be needed to effectively remove excess secretions.

C. Increase activity:

Increasing activity may be beneficial for some patients, but it might exacerbate respiratory distress in others, especially if they are already experiencing increased work of breathing. The appropriateness of increasing activity depends on the specific condition and the patient's overall stability.

D. Call the nurse for oral suctioning as needed:

This is the most appropriate choice. If the client is experiencing increased work of breathing due to copious tracheobronchial secretions, calling the nurse for oral suctioning is an intervention aimed at maintaining a clear airway and alleviating respiratory distress. Regular suctioning may be necessary to assist the client in managing secretions effectively.

Correct Answer is ["50"]

Explanation

To calculate the drops per minute for the ondansetron infusion, we need to use the formula:

drops per minute = (volume in mL x drop factor) / time in minutes

In this case, the volume is 50 mL, the drop factor is 15 gtt/mL, and the time is 15 minutes. Plugging these values into the formula, we get:

drops per minute = (50 x 15) / 15

drops per minute = 750 / 15

drops per minute = 50

Therefore, the nurse should set the infusion pump to deliver 50 drops per minute of ondansetron to the client with severe nausea.

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A client is being admitted to the medical unit to rule out cardiac issues related to valve malfunction. Which question should the nurse ask the client during the admission interview to support this diagnosis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse’s assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the patient to do?

Correct Answer is D

Explanation

A client with severe nausea has a one time order for ondansetron (Zofran) 8 mg IVPB to be administered over 15 minutes. The medication is diluted in 50 mL of D5W. The tubing drop factor is 15 gtt/mL. How many drops per minute should be given?

Correct Answer is ["50"]

Explanation

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