Which nursing intervention is priority for preventing complications of rheumatic heart disease?
Educate the client on the importance of regular exercise
Encourage the client to have routine dental cleaning
Monitor the client’s blood pressure regularly
Administer antibiotics as prescribed and before dental procedures
The Correct Answer is D
Choice A reason: Regular exercise benefits general health but is not the priority for preventing rheumatic heart disease complications, which primarily involve valvular damage from streptococcal infections. Antibiotic prophylaxis is critical to prevent endocarditis, making this a less urgent intervention compared to antibiotic administration.
Choice B reason: Routine dental cleaning reduces infection risk but is not the priority intervention. Administering antibiotics before dental procedures prevents endocarditis in rheumatic heart disease, as oral bacteria can infect damaged valves. This makes dental cleaning secondary to antibiotic prophylaxis in priority.
Choice C reason: Monitoring blood pressure is important for cardiovascular health but does not directly prevent rheumatic heart disease complications like endocarditis. Antibiotic prophylaxis before invasive procedures is the priority to protect damaged valves, making blood pressure monitoring a less critical intervention in this context.
Choice D reason: Administering antibiotics as prescribed and before dental procedures is the priority to prevent bacterial endocarditis, a major complication of rheumatic heart disease. Prophylaxis protects damaged heart valves from infection during invasive procedures, making this the correct intervention to prioritize for complication prevention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: An elevated platelet count does not indicate warfarin overdose, which prolongs clotting time by inhibiting vitamin K-dependent factors, not platelet function. Normal or low platelets may cause bleeding, but INR is the key indicator, making this incorrect for assessing overdose.
Choice B reason: Elevated aPTT reflects heparin’s effect, not warfarin, which primarily affects prothrombin time and INR. While bleeding may occur, aPTT is not the primary test for warfarin overdose, making this incorrect, as INR directly monitors warfarin’s anticoagulant effect and overdose risk.
Choice C reason: An elevated lipid panel is unrelated to warfarin overdose, which causes bleeding by inhibiting clotting factors. Lipid levels affect atherosclerosis, not coagulation, making this incorrect, as INR is the specific test to assess warfarin’s therapeutic and overdose effects in bleeding patients.
Choice D reason: An elevated INR level indicates warfarin overdose, as warfarin inhibits vitamin K-dependent clotting factors, prolonging prothrombin time and increasing bleeding risk like bruising and nosebleeds. Monitoring INR is critical, making this the correct test to identify overdose in this patient.
Correct Answer is C
Explanation
Choice A reason: A blood pressure of 118/78 mmHg is normal (systolic <120 and diastolic <80), not stage 1 hypertension (systolic 130–139 or diastolic 80–89). This is incorrect, as it does not meet the criteria for hypertension, requiring clarification for the nurses’ understanding.
Choice B reason: A blood pressure of 122/80 mmHg is elevated (systolic 120–129 and diastolic <80), not stage 1 hypertension, which requires systolic 130–139 or diastolic 80–89. This is incorrect, as it falls below the threshold for stage 1 classification in hypertension guidelines.
Choice C reason: A blood pressure of 132/88 mmHg falls within stage 1 hypertension (systolic 130–139 or diastolic 80–89), requiring lifestyle changes and possible medication. This is the correct example, as it accurately represents the classification for stage 1 hypertension in clinical practice.
Choice D reason: A blood pressure of 162/98 mmHg indicates stage 2 hypertension (systolic ≥140 or diastolic ≥90), not stage 1. This is incorrect, as it exceeds the stage 1 range, requiring the nurse to distinguish it from the milder stage 1 classification.
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