The nurse is caring for a 64-year-old patient admitted with mitral valve regurgitation. Which information obtained by the nurse when assessing the patient should be communicated to the health care provider immediately?
a. The patient has bilateral crackles.
b. The patient has bilateral, 4+ peripheral edema.
c. The patient has a loud systolic murmur across the precordium.
d. The patient has a palpable thrill felt over the left anterior chest.
ANS: A
Crackles that are audible throughout the lungs indicate that the patient is experiencing severe left ventricular failure with pulmonary congestion and needs immediate interventions such as diuretics. A systolic murmur and palpable thrill would be expected in a patient with mitral regurgitation. Although 4+ peripheral edema indicates a need for a change in therapy, it does not need to be addressed urgently.
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