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. Monitor blood pressure – While important, blood pressure changes are not the most sensitive or early indicator of fluid retention in heart failure.
B. Assess radial pulses – Pulse assessment can reflect cardiac output, but it does not directly indicate fluid balance.
C. Monitor bowel movements – Bowel function is not typically affected by fluid balance in heart failure and is not a relevant measure.
D. Monitor weight daily – Daily weight monitoring is the most accurate and early indicator of fluid retention in clients with heart failure. A weight gain of 2–3 pounds in a day or 5 pounds in a week may indicate fluid overload and should be reported to the healthcare provider.
Correct Answer is A
Explanation
A. Ventricular tachycardia is characterized by a ventricular rate >100 bpm, regular rhythm, no visible P waves, and wide QRS complexes (>0.12 seconds). The findings described—ventricular rate of 162, regular R-R intervals, no visible P waves, and a QRS duration of 0.18 seconds—are consistent with ventricular tachycardia.
B. Ventricular fibrillation shows a chaotic, irregular rhythm with no identifiable QRS complexes, which is not the case here.
C. Sinus tachycardia would have visible P waves and a normal QRS duration.
D. Atrial flutter typically has "sawtooth" flutter waves and a more organized atrial rhythm with a distinct P wave pattern, which is absent in this scenario.
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