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 C
Explanation
Choice A rationale
A respiratory rate of 18/min is within the normal range for adults and does not typically require immediate intervention.
Choice B rationale
A blood pressure of 102/66 mm Hg is within the normal range for adults and does not typically require immediate intervention.
Choice C rationale
Yellow-green drainage from a surgical incision suggests infection and should be reported to the provider immediately for further evaluation and management.
Choice D rationale
Straw-colored urine from an indwelling urinary catheter is a normal finding and indicates adequate hydration and kidney function
Correct Answer is ["B","C"]
Explanation
Choice A rationale
Fat neck veins are not a typical finding in a client with frequent vomiting and diarrhea. Dehydration, which is common in such cases, usually leads to flat neck veins due to reduced intravascular volume.
Choice B rationale
Hypotension is a common finding in clients with frequent vomiting and diarrhea due to fluid loss and dehydration. The loss of fluids leads to a decrease in blood volume, resulting in low blood pressure.
Choice C rationale
Poor skin turgor is a classic sign of dehydration, which is expected in clients with frequent vomiting and diarrhea. Dehydration causes the skin to lose its elasticity, leading to poor skin turgor.
Choice D rationale
Bradycardia is not typically associated with dehydration. In fact, dehydration often leads to tachycardia (increased heart rate) as the body tries to compensate for the reduced blood volume.
Choice E rationale
Pale yellow urine is not a typical finding in dehydration. Dehydration usually leads to concentrated urine, which is darker in color. Pale yellow urine indicates adequate hydration.
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