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 A
Explanation
A. An echocardiogram is the most helpful noninvasive tool for diagnosing cardiomyopathy. It provides detailed information about chamber size, wall motion, ventricular function, and left ventricular hypertrophy, all of which are essential in evaluating cardiomyopathy.
B. Arterial blood gases (ABGs) assess oxygenation and acid-base balance but do not provide structural or functional cardiac details.
C. Swan-Ganz analysis (pulmonary artery catheter) can measure pressures in the heart but is invasive and typically used for hemodynamic monitoring, not initial diagnosis.
D. Cardiac catheterization can show coronary anatomy and pressures, but it is not the first-line test for evaluating cardiomyopathy unless ischemic disease is suspected.
Correct Answer is []
Explanation
Potential Condition: Atrial Fibrillation
The client presents with an irregular, tachycardic rhythm with unclear P waves, which are classic signs of atrial fibrillation (AF). Symptoms such as palpitations, dizziness, and shortness of breath are common with AF, particularly with a rapid ventricular response.
Actions to Take
• Administer an anticoagulant: AF increases the risk of thrombus formation in the atria, which can lead to embolic stroke. Anticoagulation reduces this risk, especially in symptomatic or persistent cases.
• Obtain a 12-lead ECG: This helps confirm the diagnosis, assess the rhythm in detail, and rule out other arrhythmias or ischemic changes that may be present.
Parameters to Monitor
• Manifestations of stroke: Clients with AF are at increased risk for embolic stroke. Neurological status should be closely monitored for signs of confusion, facial droop, weakness, or speech changes.
• PTT/INR: These lab values help assess coagulation status, particularly when anticoagulants such as warfarin or heparin are initiated, to ensure therapeutic levels and avoid bleeding complications.
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