A nurse is assessing a client who has infective endocarditis. Which of the following findings should be the priority for the nurse to report to the provider?
Splinter hemorrhages to the nails
Fever
Clusters of petechiae in the mouth
Dyspnea
The Correct Answer is D
A. Splinter hemorrhages are a common sign of infective endocarditis but are not immediately life-threatening.
B. Fever is a typical manifestation of infection and expected in infective endocarditis, not a priority unless unresponsive to treatment.
C. Clusters of petechiae in the mouth indicate microemboli or vascular involvement, but they are not an acute threat.
D. Dyspnea is the priority finding because it may indicate heart failure or pulmonary embolism, both of which are serious complications of infective endocarditis and require immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Splinter hemorrhages are a common sign of infective endocarditis but are not immediately life-threatening.
B. Fever is a typical manifestation of infection and expected in infective endocarditis, not a priority unless unresponsive to treatment.
C. Clusters of petechiae in the mouth indicate microemboli or vascular involvement, but they are not an acute threat.
D. Dyspnea is the priority finding because it may indicate heart failure or pulmonary embolism, both of which are serious complications of infective endocarditis and require immediate intervention.
Correct Answer is D
Explanation
A. Taking a diuretic before sleep can lead to nocturia (frequent urination at night), disrupting sleep. Also, fluid intake may need to be restricted, not encouraged.
B. Clients with heart failure are usually advised to limit sodium to 2 grams or less per day, not 4 grams, to help reduce fluid retention.
C. Naproxen (a NSAID) is not recommended for clients with heart failure as it can cause fluid retention and worsen the condition.
D. Slowing down when tired after exercise shows an understanding of energy conservation and pacing—appropriate for managing heart failure symptoms. This indicates that teaching was effective.
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