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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Stage 1 hypertension is classified as a systolic BP of 130-139 mm Hg or diastolic BP of 80-89 mm Hg. While the readings provided are close, the higher diastolic value of 88 mm Hg falls into the Stage 1 hypertension category.
B. The term prehypertension is outdated and replaced by elevated BP, which refers to systolic 120-129 mm Hg and diastolic <80 mm Hg. The client’s diastolic values are too high for this category.
C. A normal BP is <120/80 mm Hg, and the client’s readings exceed this range.
D. Stage 2 hypertension is ≥140/90 mm Hg, which does not apply to this client.

A. Suggest that the client use a salt substitute. B. Obtain a blood sample for a serum sodium level. C. Advise the client to add citrus juices and bananas to her diet. D. Obtain a 12-lead ECG.

Correct Answer is D

Explanation

A. Salt substitutes often contain potassium and should be avoided in hyperkalemia.
B. While assessing other electrolytes may be useful, the immediate concern is evaluating the effects of hyperkalemia on cardiac function.
C. Citrus fruits and bananas are high in potassium and should be avoided when potassium levels are elevated.
D. A 12-lead ECG is essential to assess for cardiac dysrhythmias, as hyperkalemia can cause life-threatening arrhythmias such as peaked T waves and widened QRS complexes.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a family history of hypertension. The nurse should inform the client that their blood pressure readings of 124/84 mm Hg and 128/88 mm Hg place them in which of the following categories?

Correct Answer is A

Explanation

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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