When considering the risk for heart failure, what would the nurse monitor the client diagnosed with infective endocarditis for on an ongoing basis?
Flank pain with radiation to the groin, accompanied by hematuria.
Respiratory distress, chest pain, and use of accessory muscles.
Crackles, peripheral edema, and weight gain.
Confusion, decreasing level of consciousness, and aphasia.
The Correct Answer is C
Choice A rationale
Flank pain with radiation to the groin and hematuria are more indicative of kidney issues, not heart failure.
Choice B rationale
Respiratory distress, chest pain, and use of accessory muscles can indicate respiratory issues but are not specific to heart failure.
Choice C rationale
Crackles, peripheral edema, and weight gain are classic signs of heart failure. These symptoms indicate fluid overload and poor cardiac function.
Choice D rationale
Confusion, decreasing level of consciousness, and aphasia are neurological symptoms and not specific to heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A rationale
A history of diabetes mellitus can cause delayed wound healing due to poor blood circulation and neuropathy, which can lead to reduced sensation and increased risk of infection.
Choice B rationale
A history of hyperlipidemia can contribute to delayed wound healing by causing atherosclerosis, which reduces blood flow to the wound site and impairs healing.
Choice C rationale
Wound infection is a direct cause of delayed wound healing. Infection can lead to increased inflammation, tissue damage, and prolonged healing time.
Choice D rationale
Decreased pedal perfusion indicates poor blood flow to the lower extremities, which can significantly delay wound healing by reducing the delivery of oxygen and nutrients to the wound.
Choice E rationale
Fasting blood glucose levels are important to monitor in patients with diabetes, as high glucose levels can impair the body’s ability to heal wounds effectively.
Correct Answer is D
Explanation
Choice A rationale
Dextrose 5% in water is not recommended for initial fluid resuscitation in burn patients because it does not provide the necessary electrolytes to address the fluid shifts and electrolyte imbalances that occur after a burn injury.
Choice B rationale
0.45% sodium chloride is a hypotonic solution and is not suitable for initial fluid resuscitation in burn patients. It can lead to cellular swelling and does not adequately replace the lost extracellular fluid.
Choice C rationale
Dextrose 5% in 0.9% sodium chloride is not the preferred choice for initial fluid resuscitation in burn patients. While it provides both glucose and electrolytes, it is not as effective as Lactated Ringers in addressing the specific needs of burn patients.
Choice D rationale
Lactated Ringers is the recommended fluid for initial resuscitation in burn patients. It is an isotonic solution that helps to restore circulating volume, correct electrolyte imbalances, and prevent hypovolemic shock.
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