The nurse is assessing a client who had valve replacement surgery yesterday. It would be a priority for the nurse to report which assessment finding to the healthcare provider?

Urinary output 275ml over last 8 hours

Hemoglobin 14g/dl (12-16 g/dl)

Heart rate 110 and irregular

Oral temperature 99.2◦FA

Answer and Explanation

The Correct Answer is C

a. Urinary output 275ml over the last 8 hours: While urinary output is an important parameter to monitor, especially in post-operative patients, a urinary output of 275ml over 8 hours is within an acceptable range. It is important to ensure adequate renal perfusion and urine output, but this finding does not raise immediate concerns.

b. Hemoglobin 14g/dl (12-16 g/dl): A hemoglobin level of 14g/dl is within the normal range and does not indicate any immediate issues with oxygen-carrying capacity or blood loss. While it is important to monitor hemoglobin levels post-operatively, this finding does not require immediate action.

c. Heart rate 110 and irregular: A heart rate of 110 beats per minute (bpm) and irregular rhythm is concerning, especially in a post-operative patient who recently underwent valve replacement surgery. An irregular heart rate could indicate cardiac dysrhythmias, which may be related to the surgery or underlying cardiac issues. This finding warrants further evaluation and may require intervention, making it a priority for the nurse to report to the healthcare provider.

d. Oral temperature 99.2°F: An oral temperature of 99.2°F is slightly elevated but is not significantly outside the normal range. While fever can indicate infection, post-operative patients can have mild elevations in temperature due to the inflammatory response to surgery. Unless accompanied by other signs of infection or instability, this finding may not be a priority for immediate reporting.

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Correct Answer is B

Explanation

a. Hemolytic anemia: Hemolytic anemia is more commonly associated with mechanical heart valves rather than tissue valves. Mechanical valves can cause damage to red blood cells as they move through the valve, leading to hemolysis and subsequent anemia. Tissue valves typically do not cause significant hemolysis.

b. Endocarditis: Endocarditis is a known complication associated with prosthetic heart valves, including tissue valves. While tissue valves generally have a lower risk of thrombosis compared to mechanical valves, they are still susceptible to bacterial colonization and subsequent endocarditis. Patients with prosthetic heart valves, regardless of type, are recommended to take antibiotic prophylaxis before certain dental or surgical procedures to reduce the risk of infective endocarditis

c. Hypertension: Hypertension is not specifically associated with tissue valve replacements. While hypertension is a common cardiovascular condition, it is not directly related to the type of prosthetic valve implanted.

d. Elevated PT/INR: Elevated prothrombin time (PT) and international normalized ratio (INR) are more commonly associated with mechanical heart valves rather than tissue valves. Mechanical valves require lifelong anticoagulation therapy with medications such as warfarin to prevent thrombosis. Tissue valves generally do not require long-term anticoagulation therapy, although they may still require short-term anticoagulation immediately after implantation.

A. Check groin dressing B. Review current H&H C. Check blood glucose D. Assess pain level

Correct Answer is D

Explanation

a. Check groin dressing: While monitoring the dressing is important, it is not the top priority immediately after the procedure. The nurse should assess other critical aspects first.
b. Review current H&H (hemoglobin and hematocrit): Although monitoring hemoglobin and hematocrit levels is essential, it is not the highest priority at this moment. Immediate post-procedure concerns take precedence.
c. Check blood glucose: Blood glucose monitoring is important, especially if the client has diabetes or other risk factors. However, it is not the priority right after the procedure.
d. Assess pain level: This is the priority intervention. The nurse should assess the client’s pain level, especially at the insertion site. Pain could indicate complications such as bleeding, hematoma, or vascular injury.

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The nurse is assessing a client who had valve replacement surgery yesterday. It would be a priority for the nurse to report which assessment finding to the healthcare provider?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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