When considering the risk for heart failure, what would the nurse monitor the client diagnosed with infective endocarditis for on an ongoing basis?
Flank pain with radiation to the groin, accompanied by hematuria.
Respiratory distress, chest pain, and use of accessory muscles.
Crackles, peripheral edema, and weight gain.
Confusion, decreasing level of consciousness, and aphasia.
The Correct Answer is C
Choice A rationale
Flank pain with radiation to the groin and hematuria are more indicative of kidney issues, not heart failure.
Choice B rationale
Respiratory distress, chest pain, and use of accessory muscles can indicate respiratory issues but are not specific to heart failure.
Choice C rationale
Crackles, peripheral edema, and weight gain are classic signs of heart failure. These symptoms indicate fluid overload and poor cardiac function.
Choice D rationale
Confusion, decreasing level of consciousness, and aphasia are neurological symptoms and not specific to heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While pain management is important, maintaining the airway is the priority intervention for a client with deep partial- and full-thickness burns to the face, chest, abdomen, and upper arms. Burns to the face and chest can cause airway edema and compromise breathing.
Choice B rationale
Maintaining the airway is the priority intervention during the resuscitation phase of injury for a client with burns to the face, chest, abdomen, and upper arms. Airway edema can develop rapidly, and securing the airway is crucial to ensure adequate oxygenation and ventilation.
Choice C rationale
Inserting an indwelling urinary catheter is important for monitoring urine output and fluid balance, but it is not the priority intervention. Airway management takes precedence in this scenario.
Choice D rationale
Initiating fluid resuscitation is essential for managing burn shock and maintaining hemodynamic stability, but maintaining the airway is the priority intervention to ensure the client can breathe adequately.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Palpate the area behind the ankle bone. This action is correct. The posterior tibial pulse is located behind the medial malleolus (ankle bone), and palpating this area is necessary to assess the pulse.
Choice B rationale
Use the pads of the fingers to feel for the pulse. This action is correct. Using the pads of the fingers provides a more sensitive and accurate assessment of the pulse compared to using the fingertips or thumb.
Choice C rationale
Compare the pulse strength with the other leg. This action is correct. Comparing the pulse strength bilaterally helps identify any discrepancies that may indicate vascular issues.
Choice D rationale
Assess for any swelling or tenderness. This action is incorrect. While assessing for swelling or tenderness is essential in a general physical examination, it is not a specific step in assessing the posterior tibial pulse.
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