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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Standing with feet close together when lifting an object does not provide adequate support or balance, increasing the risk of injury. Proper body mechanics involve keeping feet apart for a stable base of support.
B. Putting weight on the heels when moving an object is not advised. Instead, one should keep the weight distributed over the whole foot for stability.
C. When pushing an object, stepping forward with the front foot (rather than moving it backward) helps to maintain balance and applies proper force.
D. Facing the direction of movement is a correct application of proper body mechanics, as it prevents twisting of the spine, reduces strain on the back, and promotes safe movement.

A. Ability to recall how the injury occurred B. Pooling of blood and edema around the eyes C. Bruising over the mastoid process D. Chvostek's sign

Correct Answer is ["B","C"]

Explanation

A. Clients with a basilar skull fracture may experience confusion or memory loss regarding the injury, making them unable to recall how it occurred.
B. Pooling of blood around the eyes, known as "raccoon eyes," is a common sign of a basilar skull fracture.
C. Bruising over the mastoid process (Battle's sign) is another classic sign of a basilar skull fracture, indicating trauma to the base of the skull.
D. Chvostek's sign is associated with hypocalcemia, not basilar skull fractures.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client at a follow-up clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal?

Correct Answer is D

Explanation

A nurse has received report on a client who has a basilar skull fracture. Which of the following findings should the nurse anticipate with this client?

Correct Answer is ["B","C"]

Explanation

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