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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 ["B","C","E","F","G"]

Explanation

Choice A rationale

Potassium level is not directly related to wound healing. While potassium is essential for overall cellular function, it does not have a direct impact on the wound healing process.

Choice B rationale

Pre-albumin level is a marker of nutritional status. Low pre-albumin levels indicate poor nutrition, which can delay wound healing. Adequate protein intake is essential for the synthesis of collagen and other proteins involved in the wound healing process.

Choice C rationale

History of diabetes mellitus can significantly delay wound healing. High blood glucose levels can impair immune function, reduce blood flow, and increase the risk of infection, all of which can delay the healing process.

Choice D rationale

History of hyperlipidemia is not directly related to wound healing. While hyperlipidemia can contribute to other health issues, it does not have a direct impact on the wound healing process.

Choice E rationale

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

Choice F rationale

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

Choice G rationale

Fasting blood glucose levels are an indicator of blood sugar control. High fasting blood glucose levels can impair immune function and increase the risk of infection, both of which can delay wound healing.

A. The area surrounding the insertion site feels warm to the touch. B. The infusion rate has stopped but the tubing is not kinked. C. There is fluid leaking around the insertion site. D. There is no blood return when the tubing is aspirated.

Correct Answer is A

Explanation

Choice A rationale

Warmth around the IV insertion site is a classic sign of phlebitis, which is inflammation of the vein. This can be caused by irritation from the IV catheter or the infusing solution.

Choice B rationale

A stopped infusion rate without a kinked tubing could indicate an occlusion or infiltration, but it is not a specific sign of phlebitis.

Choice C rationale

Fluid leaking around the insertion site suggests infiltration or extravasation, where the IV fluid leaks into the surrounding tissue, rather than phlebitis.

Choice D rationale

Lack of blood return when aspirating the tubing could indicate a positional issue or occlusion, but it is not specific to phlebitis.

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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?

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is ["B","C","E","F","G"]

Explanation

A nurse is working with a licensed practical nurse (LPN) to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse the client has phlebitis at the IV insertion site?

Correct Answer is A

Explanation

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