Following valve replacement surgery, the patient is instructed to notify the health care provider if fever, increased heart rate, fatigue, malaise, anorexia, weight loss, headache, chills, and/or night sweats occur
What is the nurse's rationale for this instruction? 1. These are manifestation of valve rejection.
2. These are manifestations of the type of heart failure associated with valve replacement.
3. These findings suggest that the patient is having a myocardial infarction.
4. These findings are manifestations of infective endocarditis.
4
Rationale 1: Replacement valves are not vascular; therefore rejection does not occur.
Rationale 2: Heart failure is manifested with lung congestion and shortness of breath.
Rationale 3: Myocardial infarction (MI) is manifested by chest pain and can result in fatigue with increased heart rate. The other manifestation of fever, anorexia, malaise, and chills are not associated with MI.
Rationale 4: The clinical manifestations are a sign of postoperative infective endocarditis, which needs immediate medical attention.
You might also like to view...
The ICU unit has a client in which the family has been verbally abusive and has threatened staff. The manager notes an increase in absenteeism with the staff over the past 2 days. The manager believes this is attributed to a:
1. Staffing dilemma caused by the scheduler. 2. Change in the staffing matrix. 3. Decline in staff morale due to a hostile environment. 4. Miscommunication between management and nursing administration.
Which of the following patients scheduled for an interventional radiology procedure requiring administration of radiocontrast dye would be considered at high risk for nephrotoxicity? Select all that apply
A) A 14-year-old with severe abdominal pain B) A 25-year-old with a history of glomerular nephritis who is complaining of severe flank pain C) A 67-year-old diabetic undergoing diagnostic testing for new-onset proteinuria D) A 45-year-old with elevated liver enzymes possibly due to fatty liver cirrhosis E) A 53-year-old male undergoing biopsy for a suspicious "spot" on his chest x-ray
A nurse caring for a client with atrial fibrillation who is started on digoxin therapy is required to monitor plasma drug levels. The nurse would report which level to the primary health care provider?
A) 1.6 ng/mL B) 1.8 ng/mL C) 2.0 ng/mL D) 2.2 ng/mL
What information should a nurse include when providing information to a patient using topical eye medications?
a. Look upward and drop the medication into the inner canthus. b. Pull the lower eyelid down and drop the medication into the conjunctival sac. c. Hold both eyelids open and drop the me-dication onto the sclera. d. Tilt the head to the side and drop the me-dication into the outer canthus.