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 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.

A. Fried fish sandwich and potato salad B. Baked turkey and salad C. Biscuits with sausage gravy and sliced tomatoes D. Barbecued ribs and canned baked beans

Correct Answer is B

Explanation

A. Fried fish sandwich and potato salad: Fried foods are high in unhealthy fats, which can increase cholesterol levels and are not recommended for clients after a myocardial infarction.

B. Baked turkey and salad: This is a healthy choice, as baked turkey is low in fat, and a salad provides nutrients without excessive fat or cholesterol, supporting heart health.

C. Biscuits with sausage gravy and sliced tomatoes: Biscuits and sausage gravy are high in saturated fats, which are not appropriate for a heart-healthy diet.

D. Barbecued ribs and canned baked beans: Barbecued ribs and canned baked beans may contain high levels of saturated fats, sugar, and sodium, which are not recommended for someone recovering from a myocardial infarction.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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