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 C
Explanation
A. Strict bed rest is not the priority; early mobility may be encouraged once the patient is stable.
B. Pain management is important but not the first priority in septic shock.
C. Monitoring vital signs frequently is the priority because it allows the nurse to detect changes in perfusion, blood pressure, heart rate, and oxygenation status, which are critical for timely intervention in septic shock.
D. Assisting with hygiene is part of routine care but is not a priority during the acute management of septic shock.
Correct Answer is A
Explanation
A. Epinephrine – Epinephrine is the first-line treatment for anaphylactic shock. It rapidly reverses airway constriction, hypotension, and swelling by stimulating alpha and beta-adrenergic receptors, leading to bronchodilation, vasoconstriction, and increased cardiac output.
B. Dobutamine – Dobutamine is a positive inotrope used to treat cardiogenic shock and may support cardiac output, but it does not address the airway or allergic component of anaphylaxis.
C. Methylprednisolone – This corticosteroid may be given to reduce inflammation and prevent delayed reactions, but it has a slower onset of action and is not the priority in emergency management.
D. Furosemide – This diuretic is used in fluid overload or pulmonary edema, not in the management of anaphylaxis.
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