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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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Checking the circulation of the affected extremity is crucial because the greatest risk to the client is neuromuscular injury resulting from compartment syndrome. Compartment syndrome is a serious condition that occurs when there’s increased pressure within the muscles, leading to decreased blood flow, which can cause muscle and nerve damage. Early detection and intervention are essential to prevent permanent damage.

Choice B rationale

Administering additional pain medication might provide temporary relief, but it does not address the underlying issue of potential compartment syndrome. Pain unrelieved by medication is a key indicator of this condition, and addressing circulation is the priority.

Choice C rationale

Repositioning the affected extremity might help with comfort, but it does not address the potential for compartment syndrome. The primary concern is ensuring adequate blood flow to prevent tissue damage.

Choice D rationale

Documenting the findings is important for medical records, but it does not address the immediate risk of compartment syndrome. Immediate action to check circulation is necessary to prevent serious complications.

A. Prealbumin level. B. History of diabetes mellitus. C. History of hyperlipidemia. D. Wound infection. E. Decreased pedal perfusion. F. Fasting blood glucose.

Correct Answer is ["A","B","D","E","F"]

Explanation

Choice A rationale

Prealbumin level is an important indicator of nutritional status. Low prealbumin levels can indicate poor nutrition, which can delay wound healing. Adequate protein intake is essential for tissue repair and regeneration.

Choice B rationale

History of diabetes mellitus is a significant factor that can delay wound healing. Diabetes can impair blood flow and reduce the supply of oxygen and nutrients to the wound, leading to slower healing.

Choice C rationale

History of hyperlipidemia is not directly associated with delayed wound healing. While it can contribute to other health issues, it is not a primary factor in wound healing.

Choice D rationale

Wound infection is a major factor that can delay wound healing. Infections can cause inflammation, tissue damage, and increased exudate, all of which can impede the healing process.

Choice E rationale

Decreased pedal perfusion indicates poor blood flow to the lower extremities. Adequate blood flow is crucial for delivering oxygen and nutrients to the wound site, and decreased perfusion can significantly delay healing.

Choice F rationale

Fasting blood glucose levels are important in managing diabetes. High blood glucose levels can impair the immune response and reduce the body’s ability to heal wounds effectively.

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When considering the risk for heart failure, what would the nurse monitor the client diagnosed with infective endocarditis for on an ongoing basis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a full arm cast and reports a pain level of 8 on a scale of 0 to 10, which is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?

Correct Answer is A

Explanation

A nurse is caring for a client. Select the 5 findings that can cause delayed wound healing.

Correct Answer is ["A","B","D","E","F"]

Explanation

A 20-year-old diagnosed with appendicitis is being assessed by the nurse. Which statement by the client will make the nurse intervene immediately?

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A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites?

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The nurse is caring for a client prescribed digoxin to help manage heart failure. Which manifestations correlate with a digoxin level of 2.3 ng/dL? (Select all that apply.)

A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

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