A nurse is collecting data on a client who has mitral valve stenosis. Which of the following findings should the nurse expect?
Barrel chest
Bradycardia
Clubbing of the fingers
Heart murmur
The Correct Answer is D
A. Barrel chest. A barrel chest is commonly seen in chronic obstructive pulmonary disease (COPD) rather than mitral valve stenosis.
B. Bradycardia. Bradycardia is not typically associated with mitral valve stenosis, as symptoms often include rapid or irregular heartbeat.
C. Clubbing of the fingers. Clubbing is associated with chronic hypoxia, often due to pulmonary conditions, not specifically with mitral valve stenosis.
D. Heart murmur. Mitral valve stenosis causes turbulent blood flow through the narrowed valve, resulting in a characteristic murmur.
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Correct Answer is C
Explanation
A. 25 gtt/min: Calculating the correct rate reveals that this is not the correct answer.
B. 1500 gtt/min: This rate is too high; the calculation does not support this answer.
C. 50 gtt/min: To calculate: (100 mL / 120 min) × 30 gtt/mL = 50 gtt/min.
D. 83 gtt/min: This is too high based on the calculation.
Correct Answer is B
Explanation
A. Swelling of the lower extremity can create a wound that is difficult to heal. Swelling typically relates to venous ulcers, not arterial ulcers, which are caused by reduced blood flow.
B. Decreased blood flow to the area can cause the wound and decrease the healing. Peripheral artery disease causes decreased blood flow, leading to poor oxygenation and slow healing of arterial ulcers.
C. Lower extremity compression stockings likely caused the wound to occur. Compression stockings are used in venous insufficiency and do not cause arterial ulcers.
D. Increased blood sugar associated with the condition is likely the cause of the wound not healing. While high blood sugar can impair healing, decreased blood flow is the primary cause of arterial ulcers in PAD.