A nurse is caring for a patient diagnosed with infectious endocarditis. The nurse is aware that which of the following are potential assessment findings? (SELECT ALL THAT APPLY)
Osler Nodes
Splinter Hemorrhages
Petechial Hemorrhaging
Janeway Lesions
Fever with Chills
Correct Answer : A,B,C,D,E
A. Osler Nodes – These are tender, painful nodules on the fingers and toes, a classic sign of infective endocarditis.
B. Splinter Hemorrhages – Tiny blood clots under the fingernails occur due to microembolization from infected heart valves.
C. Petechial Hemorrhaging – Small red or purple spots on the skin or mucous membranes occur due to embolization of infected material.
D. Janeway Lesions – Painless, flat, red spots on the palms and soles caused by microemboli.
E. Fever with Chills – A common systemic symptom due to infection and inflammation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Counting the number of QRS complexes in a 6-second strip and multiplying by 10 provides an estimate of the heart rate per minute.
B. Measuring T waves is used to assess repolarization abnormalities, not to determine heart rate.
C. While the monitor provides a heart rate reading, manual calculation is essential for verifying accuracy.
D. P waves indicate atrial activity but are not used to calculate the overall heart rate.
Correct Answer is B
Explanation
A. Taking a diuretic before bed can lead to nocturia and disrupt sleep. It is usually recommended to take it in the morning.
B. Daily weight tracking helps detect fluid retention, a key indicator of worsening heart failure. A weight gain of 2 lbs in 24 hours or 5 lbs in a week should be reported to the provider.
C. NSAIDs (e.g., naproxen) should be avoided as they can cause fluid retention and worsen heart failure.
D. Sodium intake should be limited to 2 grams (2000 mg) per day, not 4 grams, to help prevent fluid overload.
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