A nurse is speaking with the family member of a client who is receiving chemotherapy.The family member asks about infection prevention.
Which of the following statements made by the nurse is appropriate?

Choice A rationale

Palpitations, described as feeling the heart skip a beat, can be a symptom of various cardiac conditions, including arrhythmias, but are not singularly indicative of aortic stenosis. While aortic stenosis can lead to arrhythmias, palpitations are not the most specific or common initial complaint directly correlating with the physiological changes of a narrowed aortic valve.

Choice B rationale

Dyspnea on exertion, or shortness of breath with exercise, is a cardinal symptom of aortic stenosis. As the aortic valve narrows, the left ventricle must generate increasingly higher pressures to eject blood into the aorta. During exercise, cardiac output demands increase, and the stenosed valve restricts blood flow, leading to exertional dyspnea due to elevated left ventricular end-diastolic pressure and pulmonary congestion.

Choice C rationale

Pitting edema in the feet and ankles suggests fluid retention, which is a common manifestation of right-sided heart failure. While severe aortic stenosis can eventually lead to biventricular heart failure, peripheral edema is not typically the earliest or most specific symptom directly linked to the mechanical obstruction of the aortic valve itself. It is a later manifestation of cardiac decompensation.

Choice D rationale

Chest pain that resolves with rest is characteristic of stable angina, often caused by coronary artery disease. While patients with severe aortic stenosis can experience anginal chest pain due to increased myocardial oxygen demand from ventricular hypertrophy and reduced coronary perfusion, this symptom is not as specific to aortic stenosis as exertional dyspnea, which directly reflects the flow obstruction.

Choice A rationale

Inserting an indwelling urinary catheter is important for monitoring urine output, which is a key indicator of fluid resuscitation adequacy in burn patients. However, establishing intravenous access for fluid resuscitation precedes catheter insertion, as inadequate fluid volume can lead to acute kidney injury despite monitoring.

Choice B rationale

Administering pain medications is crucial for client comfort and reduces the stress response, but it is not the immediate priority after assessing ABCs in a major burn injury. Restoring circulating fluid volume is paramount to prevent burn shock and maintain organ perfusion.

Choice C rationale

Inserting 2 large-bore intravenous catheters for fluid resuscitation is the next critical priority after assessing ABCs in a major burn injury. Large-bore access allows for rapid infusion of large volumes of crystalloid fluids to combat the massive fluid shifts and hypovolemic shock characteristic of emergent phase burns.

Choice D rationale

Preparing for a possible escharotomy may be necessary if circumferential burns impair circulation or ventilation, but it is not the immediate next step after ABC assessment. Fluid resuscitation takes precedence to prevent shock before addressing potential compartment syndrome or respiratory compromise requiring an escharotomy.