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 D

Explanation

Choice A reason: Suctioning the patient immediately is not the appropriate intervention in this context. Suctioning can be necessary if the patient has secretions obstructing the airway, but it does not address the issues of bradycardia (low heart rate) and hypotension (low blood pressure) which are critical in a spinal cord injury.

Choice B reason: Administering normal saline (NS) at 25 cc/hr is not sufficient to address the patient's hypotension. In a patient with a spinal cord injury at the T5 level, hypotension is likely due to neurogenic shock, and more aggressive fluid resuscitation or pharmacological support is needed.

Choice C reason: Raising the head of the bed is not appropriate for managing the patient's condition. In fact, keeping the head elevated can worsen hypotension by reducing venous return to the heart. The focus should be on stabilizing blood pressure and heart rate.

Choice D reason: The correct intervention is starting a dopamine IV drip. Dopamine is a vasopressor that helps increase blood pressure and heart rate, which is crucial in managing neurogenic shock. By administering dopamine, the nurse can help stabilize the patient's cardiovascular status and improve perfusion to vital organs.

A. Woman with a blood pressure of 158/90 mm Hg. B. Patient with Kussmaul respirations. C. Man with skin itching from head to toe. D. Patient with halitosis and stomatitis.

Correct Answer is B

Explanation

Choice A reason: A blood pressure of 158/90 mm Hg in a patient with chronic kidney disease (CKD) is elevated and requires management to prevent complications. However, it is not as immediately life-threatening as Kussmaul respirations, which indicate severe metabolic acidosis.

Choice B reason: The patient with Kussmaul respirations should be assessed first. Kussmaul respirations are deep, labored breathing patterns typically associated with severe metabolic acidosis, such as diabetic ketoacidosis (DKA) or severe kidney failure. This condition requires immediate intervention to correct the underlying acidosis and stabilize the patient's condition.

Choice C reason: Itching (pruritus) is a common symptom in CKD due to the accumulation of uremic toxins. While it can be very uncomfortable and requires treatment, it is not as urgent as Kussmaul respirations, which indicate a potentially life-threatening situation.

Choice D reason: Halitosis (bad breath) and stomatitis (inflammation of the mouth) can occur in CKD due to the buildup of uremic toxins and other factors. These symptoms need attention, but they do not indicate an immediate threat to the patient's life compared to Kussmaul respirations.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a patient who experienced a spinal cord injury at the T5 level 24 hours ago. Assessment findings are:Temp: 99.0°FHR: 46 beats/minBP: 78/52 mmHgRR: 20 breaths/minSaO2: 94% on 2L NCWhich of the following interventions should the nurse anticipate?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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