A nurse cares for a patient recovering from mechanical valve replacement surgery. The patient asks, "Why will I need to take anticoagulants for the rest of my life?" What is the best response by the nurse?

"Blood clots form more easily in mechanical replacement valves."

"The vein taken from your leg reduces circulation in the leg."

"The valve replacement surgery left a lot of small clots in your heart and lungs."

"The mechanical valve places you at greater risk for a heart attack."

Answer and Explanation

The Correct Answer is A

Choice A reason: Blood clots form more easily in mechanical replacement valves due to the artificial surface of the valve, which can cause the blood to clot more readily. This increases the risk of thromboembolic events, such as stroke or valve obstruction. Therefore, patients with mechanical valves need to take anticoagulants for life to prevent clot formation and ensure the valve functions effectively.

Choice B reason: The statement that the vein taken from the leg reduces circulation in the leg is incorrect in this context. Vein grafts from the leg are typically used in coronary artery bypass grafting (CABG) surgery, not in valve replacement surgery. Therefore, this explanation does not apply to the patient's situation of needing anticoagulants after valve replacement surgery.

Choice C reason: The idea that the valve replacement surgery left a lot of small clots in the heart and lungs is not accurate. The surgery itself does not leave clots; rather, the ongoing risk of clot formation is due to the presence of the mechanical valve. This risk necessitates lifelong anticoagulation.

Choice D reason: The mechanical valve does not place the patient at a greater risk for a heart attack specifically. The concern with mechanical valves is the increased risk of blood clot formation, which is why anticoagulants are prescribed. Heart attacks are typically caused by blockages in the coronary arteries, which is a different issue.

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Correct Answer is C

Explanation

Choice A reason: Rechecking all of the patient's vital signs is a good practice, but it is not the priority action in this scenario. The patient's symptoms indicate a potential case of autonomic dysreflexia, a life-threatening condition that requires immediate action to reduce blood pressure and address the cause. Rechecking vital signs alone will not resolve the underlying issue.

Choice B reason: Elevating the patient's knees and lowering the head of the bed is not an appropriate action in this situation. This position could potentially increase intracranial pressure and exacerbate the patient's condition. The focus should be on measures that will help lower the blood pressure and alleviate the symptoms of autonomic dysreflexia.

Choice C reason: The priority action is to elevate the head of the bed immediately and notify the provider. Elevating the head of the bed helps to decrease blood pressure and improve venous return. Promptly notifying the provider ensures that the patient receives timely medical intervention to address the underlying cause of autonomic dysreflexia, which is critical for preventing further complications.

Choice D reason: Administering PRN Tylenol for the patient's headache is not the priority in this situation. While pain management is important, the patient's symptoms suggest a more severe condition (autonomic dysreflexia) that requires immediate attention to lower blood pressure and address the root cause. Pain medication alone will not resolve the underlying issue and could delay necessary interventions.

A. pH 7.50, pO2 85, pCO2 35, HCO3 30 mEq/L B. pH 7.30, pO2 90, pCO2 35, HCO3 20 mEq/L C. pH 7.50, pO2 95, pCO2 25, HCO3 22 mEq/L D. pH 7.30, pO2 80, pCO2 55, HCO3 22 mEq/L

Correct Answer is D

Explanation

Choice A reason: The values pH 7.50, pO2 85, pCO2 35, HCO3 30 mEq/L indicate alkalosis with a high bicarbonate level, which is not consistent with the patient’s slow respiratory rate that would typically lead to respiratory acidosis.

Choice B reason: The values pH 7.30, pO2 90, pCO2 35, HCO3 20 mEq/L indicate metabolic acidosis with normal pCO2, which does not align with the respiratory issue described (hypoventilation).

Choice C reason: The values pH 7.50, pO2 95, pCO2 25, HCO3 22 mEq/L indicate respiratory alkalosis, which is characterized by a low pCO2. This is not consistent with the patient’s hypoventilation, which would lead to elevated pCO2 levels.

Choice D reason: The values pH 7.30, pO2 80, pCO2 55, HCO3 22 mEq/L indicate respiratory acidosis, which aligns with the patient’s hypoventilation due to anesthesia effects and incisional pain. The elevated pCO2 and decreased pH are consistent with reduced respiratory rate and shallow breathing.

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