A nurse is contributing to the plan of care for a client who is 24 hr postoperative following an aortic valve replacement with a biologic valve. Which of the following interventions should the nurse include in the plan?
Apply a cooling blanket
Monitor daily weight
Provide opioid medications on an as needed basis
PTT levels
The Correct Answer is B
A. A cooling blanket is not typically needed unless there is a fever or postoperative temperature dysregulation, which is not a standard intervention in this case.
B. Monitoring daily weight is essential following valve replacement to detect fluid retention or heart failure, which can indicate compromised cardiac function.
C. Opioid medications may be necessary, but they should be prescribed according to the client’s pain needs rather than a routine intervention.
D. PTT levels are usually monitored for clients on anticoagulants, but since the client has a biologic valve, anticoagulation therapy is not always required as with mechanical valves.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Applying ice to the extremity is generally not recommended for DVT due to the risk of promoting vasoconstriction and worsening the condition; warm compresses are usually indicated instead.
B. There is no need to restrict oral fluids for a client with DVT unless there are other specific medical reasons; hydration is important.
C. Vasodilating medications are not standard treatment for DVT and may not be appropriate; anticoagulants are typically the primary treatment.
D. Monitoring platelet levels is important in managing DVT, especially when anticoagulants are used, to assess for potential complications such as heparin-induced thrombocytopenia (HIT), making this option correct.
Correct Answer is D
Explanation
A. Nicardipine is a calcium channel blocker primarily used to manage blood pressure but does not directly reduce ICP.
B. Phenytoin is an anticonvulsant used to prevent seizures, which may occur after a hemorrhage, but it does not address increased ICP.
C. Dopamine is used to increase blood pressure and cardiac output but does not play a role in reducing ICP.
D. Mannitol is an osmotic diuretic that helps decrease ICP by drawing fluid from brain tissue into the bloodstream, thus relieving pressure within the skull. It is the most appropriate intervention for managing increased ICP.
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