A nurse is providing care for a 70-year-old male client in the intensive care unit.

Exhibits

For each assessment finding, click to specify if the finding is expected or unexpected for a client post-tricuspid valve replacement surgery.

Choice A rationale

Limiting exercise to 10 minutes, 2 days per week is insufficient for cardiovascular health. Current recommendations generally advise at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity per week, along with muscle-strengthening activities at least two days a week, to reduce the risk of heart disease.

Choice B rationale

Monitoring blood pressure is a crucial preventative measure for heart disease. Hypertension is a major risk factor for cardiovascular diseases, including coronary artery disease, stroke, and heart failure. Regular blood pressure monitoring allows for early detection and management of elevated blood pressure, reducing the risk of these complications. A normal blood pressure is typically considered to be less than 120/80 mmHg.

Choice C rationale

Losing weight if necessary is an important recommendation for preventing heart disease. Obesity and being overweight are significant risk factors for hypertension, dyslipidemia, type 2 diabetes, and sleep apnea, all of which increase the risk of heart disease. Achieving and maintaining a healthy weight through diet and exercise can significantly reduce cardiovascular risk.

Choice D rationale

Eating a diet high in saturated fats increases the risk of heart disease. Saturated fats can raise low-density lipoprotein (LDL) cholesterol levels, which contribute to the formation of atherosclerotic plaques in the arteries, increasing the risk of coronary artery disease and stroke. Dietary guidelines recommend limiting saturated fat intake.

Choice E rationale

Maintaining the current cholesterol level may not be a preventative measure if the current cholesterol level is elevated. High levels of LDL cholesterol are a major risk factor for heart disease. Preventative measures often include lifestyle modifications and, if necessary, medication to lower elevated cholesterol levels to reduce cardiovascular risk. Normal total cholesterol is generally less than 200 mg/dL, LDL cholesterol less than 100 mg/dL, and HDL cholesterol greater than 60 mg/dL.

Choice A rationale

Active tuberculosis is an airborne infection transmitted through droplet nuclei that can remain suspended in the air for extended periods. Placing the client in a private room with a special ventilation system, such as negative pressure with high-efficiency particulate air (HEPA) filtration and air exchange directly to the outside, prevents the spread of these infectious particles to other areas and individuals.

Choice B rationale

Assigning the client to a room with other clients who require droplet precautions is inappropriate for tuberculosis. Droplet precautions are used for infections transmitted by larger respiratory droplets that travel short distances (e.g., influenza), while airborne precautions with a negative pressure room are necessary for tuberculosis.

Choice C rationale

Modifying the protocol for donning and removing personal protective equipment (PPE) before entering or leaving the client's room is unsafe. Strict adherence to established airborne precautions, including wearing an N95 respirator, is crucial to protect healthcare workers from tuberculosis transmission. Modifying the protocol could compromise their safety.

Choice D rationale

Ensuring the client wears a surgical mask during all interactions with healthcare providers helps to contain respiratory secretions at the source. However, this is a source control measure and does not protect healthcare providers from inhaling airborne droplet nuclei. Healthcare providers must wear an N95 respirator for respiratory protection when in the same room as a client with active tuberculosis.