The nurse is assessing a client with a diagnosis of mitral valve stenosis. Which element of assessment data indicates that the disease is worsening?

Increase in systolic blood pressure 10 mmHg above client's norm

reports dyspnea after walking up 2 flights of stairs

Jugular vein distention and +3 peripheral edema

Complaints of epigastric pain after eating a large meal

Answer and Explanation

The Correct Answer is C

A. Increase in systolic blood pressure 10 mmHg above client's norm: A mild increase in systolic blood pressure is not a specific indicator of mitral stenosis progression. Blood pressure fluctuations may occur due to various factors and are not typically used as a primary marker of worsening valve disease.

B. reports dyspnea after walking up 2 flights of stairs: Exertional dyspnea is a common early symptom of mitral stenosis due to reduced left atrial emptying and pulmonary congestion. However, this does not necessarily indicate worsening unless the symptom becomes more severe or occurs with minimal exertion.

C. Jugular vein distention and +3 peripheral edema: These are signs of right-sided heart failure, which may result from long-standing mitral stenosis leading to pulmonary hypertension and subsequent right ventricular hypertrophy and failure. This indicates disease progression and worsening cardiac function.

D. Complaints of epigastric pain after eating a large meal: Epigastric discomfort is not a typical symptom of mitral stenosis and is more likely related to gastrointestinal issues. It does not reflect the status or progression of the cardiac condition.

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Correct Answer is ["2.5"]

Explanation

Convert the available dose from grams (Gm) to milligrams (mg):

0.15 Gm × 1000 mg/Gm = 150 mg

Desired dose = 75 mg

Available dose = 150 mg

Volume = 5 mL

Formula:

Volume to administer = Desired dose / Available dose × Volume

= 75 mg / 150 mg × 5 mL

= 0.5 × 5 mL

Volume to administer = 2.5 mL

A. Cardiovert in the synchronized mode. B. Defibrillate immediately with a biphasic machine. C. Take a full set of vital signs. D. Initiate cardiopulmonary resuscitation.

Correct Answer is B

Explanation

A. Cardiovert in the synchronized mode: Synchronized cardioversion is used for hemodynamically unstable but conscious patients with rhythms like atrial fibrillation or supraventricular tachycardia. It is not appropriate for a pulseless patient with ventricular fibrillation, as synchronization requires detectable R-waves.

B. Defibrillate immediately with a biphasic machine: The rhythm strip shows ventricular fibrillation (VF) a life-threatening arrhythmia characterized by chaotic, irregular waveform with no identifiable PQRST and no effective cardiac output. The patient is unresponsive and pulseless, making immediate defibrillation the priority action, as per Advanced Cardiac Life Support (ACLS) guidelines.

C. Take a full set of vital signs: The client is already unresponsive and pulseless, making a full set of vitals irrelevant at this moment. Immediate resuscitation efforts, including defibrillation and CPR, take priority.

D. Initiate cardiopulmonary resuscitation: While CPR is a critical part of the algorithm for pulseless rhythms, defibrillation is the first priority in ventricular fibrillation when a defibrillator is available and ready. CPR should be started immediately after the shock if no pulse returns.

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The nurse is assessing a client with a diagnosis of mitral valve stenosis. Which element of assessment data indicates that the disease is worsening?

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Naxlex Comprehensive Predictor Exams

The client is to receive an oral suspension of Drug H 75 mg PO. The nurse has Drug H available in a suspension 0.15 Gm per 5 mL. What should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["2.5"]

Explanation

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Correct Answer is B

Explanation

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