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

Choice A rationale

A history of diabetes mellitus can cause delayed wound healing due to poor blood circulation and neuropathy, which can lead to reduced sensation and increased risk of infection.

Choice B rationale

A history of hyperlipidemia can contribute to delayed wound healing by causing atherosclerosis, which reduces blood flow to the wound site and impairs healing.

Choice C rationale

Wound infection is a direct cause of delayed wound healing. Infection can lead to increased inflammation, tissue damage, and prolonged healing time.

Choice D rationale

Decreased pedal perfusion indicates poor blood flow to the lower extremities, which can significantly delay wound healing by reducing the delivery of oxygen and nutrients to the wound.

Choice E rationale

Fasting blood glucose levels are important to monitor in patients with diabetes, as high glucose levels can impair the body’s ability to heal wounds effectively.

Choice A rationale

Inserting a nasogastric (NG) tube is not the first priority in managing a client with gastrointestinal bleeding. The primary concern is to stabilize the client and assess their condition. Inserting an NG tube can be considered later to decompress the stomach and assess the extent of bleeding, but it is not the initial step.

Choice B rationale

Asking the client about the precipitating events is important for gathering information, but it is not the first priority. The immediate focus should be on assessing the client’s current condition and stabilizing them. Once the client is stable, a detailed history can be obtained.

Choice C rationale

Obtaining vital signs is the first priority in managing a client with gastrointestinal bleeding. Vital signs provide critical information about the client’s hemodynamic status and help determine the severity of the bleeding. This information is essential for guiding further interventions and ensuring the client’s stability.

Choice D rationale

Completing a head-to-toe assessment is important, but it is not the first priority. The initial focus should be on assessing the client’s vital signs to determine their hemodynamic status. A comprehensive assessment can be performed once the client’s immediate condition is stabilized.