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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.

Answer and Explanation

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.

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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

A. The ability to comply with anticoagulant therapy for life. B. The likelihood of the client experiencing body image problems. C. The physical demands of the client’s lifestyle. D. The ability to participate in a cardiac rehabilitation program.

Correct Answer is A

Explanation

Choice A rationale

The ability to comply with anticoagulant therapy for life is essential for clients undergoing mechanical valve replacement. Mechanical valves are prone to thrombus formation, which can lead to serious complications such as stroke. Therefore, lifelong anticoagulation therapy is necessary to prevent clot formation on the valve.

Choice B rationale

While body image problems may arise due to surgical scars or the presence of a mechanical valve, they are not a primary concern that needs to be assessed before surgery. The focus should be on the client’s ability to manage the medical requirements post-surgery.

Choice C rationale

The physical demands of the client’s lifestyle are important but not as critical as the ability to comply with anticoagulant therapy. The primary concern is ensuring the client can adhere to the necessary medical regimen to prevent complications.

Choice D rationale

Participation in a cardiac rehabilitation program is beneficial for recovery and improving cardiovascular health, but it is not as crucial as the ability to comply with anticoagulant therapy. The main priority is preventing thrombus formation on the mechanical valve.

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When considering the risk for heart failure, what would the nurse monitor the client diagnosed with infective endocarditis for on an ongoing basis?

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Naxlex Comprehensive Predictor Exams

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