A nurse is collecting data on a client who has infective endocarditis. The nurse should recognize which of the following findings is the priority to report to the provider?

Malaise

Dyspnea

Fever

Anorexia

Answer and Explanation

The Correct Answer is B

A. Malaise: Malaise is a common symptom of infective endocarditis, indicating generalized discomfort or fatigue. However, it is not an immediate life-threatening condition and does not require urgent intervention.

B. Dyspnea: Dyspnea is the priority because it can indicate heart failure or a pulmonary embolism, both of which are serious complications of infective endocarditis. This requires immediate attention and reporting.

C. Fever: Fever is common in infective endocarditis due to the underlying infection. While important, it is expected and usually managed with antipyretics and antibiotics. It is not as urgent as dyspnea.

D. Anorexia: Anorexia is also a common symptom of infective endocarditis but is not an immediate threat to the client’s health.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Assist with ordered exercise as needed: Mobility and exercises such as ankle pumps help promote circulation and prevent venous stasis, reducing the risk of DVT.

B. Encourage fluids: Encouraging fluids helps prevent dehydration, which reduces blood viscosity and lowers the risk of clot formation.

C. Measure affected limb circumference: Measuring limb circumference is important for detecting early signs of DVT, such as swelling in the affected limb.

D. Massage calves and thighs: Massaging the legs is contraindicated in clients at risk for DVT as it can dislodge a clot, leading to a pulmonary embolism.

E. Apply compression stockings: Compression stockings promote venous return and reduce the risk of blood pooling in the lower extremities, thus preventing DVT.

A. Use the diaphragm of the stethoscope to listen to the carotid pulsations. B. Count the apical pulsations for a full minute. C. Check the apical pulse with a Doppler device. D. Press the stethoscope firmly against the client's skin.

Correct Answer is B

Explanation

A. Use the diaphragm of the stethoscope to listen to the carotid pulsations. The apical pulse is located at the apex of the heart, not at the carotid artery. This option does not describe the correct location or use of the stethoscope.

B. Count the apical pulsations for a full minute. Counting for a full minute is the correct method for assessing an apical pulse, particularly in clients on cardiovascular medications, to ensure accurate detection of any irregularities.

C. Check the apical pulse with a Doppler device. A Doppler device is typically used to assess peripheral pulses, not the apical pulse. A stethoscope is the appropriate tool for apical pulse assessment.

D. Press the stethoscope firmly against the client's skin. While the stethoscope should be placed firmly enough to hear heart sounds, excessive pressure can distort the sounds and is not necessary.

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A nurse is collecting data on a client who has infective endocarditis. The nurse should recognize which of the following findings is the priority to report to the provider?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","C","E"]

Explanation

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Correct Answer is B

Explanation

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