Nokea
The client with endocarditis is at risk for which complication?
- A. Embolism
- B. Hypoglycemia
- C. Osteoarthritis
- D. Pancreatitis
Correct Answer: A
Rationale: Endocarditis can cause vegetations on heart valves, which may break off and form emboli.
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The nurse is preparing a client for a cardiac catheterization. Which pre-procedure instruction is most important?
- A. You will be sedated during the procedure.
- B. You must fast for 6-8 hours before the test.
- C. You can drive home after the procedure.
- D. You should avoid taking aspirin before the test.
Correct Answer: B
Rationale: Fasting prevents aspiration during sedation and ensures accurate test results.
Which assessment finding in a client with endocarditis requires immediate action?
- A. Splinter hemorrhages under nails
- B. Mild joint pain
- C. New heart murmur
- D. Fatigue after activity
Correct Answer: C
Rationale: A new heart murmur may indicate valve damage or worsening infection, requiring urgent evaluation.
The nurse and an unlicensed assistive personnel (UAP) are bathing a bedfast client. Which action by the UAP warrants immediate intervention?
- A. The UAP closes the door and cubicle curtain before undressing the client.
- B. The UAP begins to massage and rub lotion into the client’s calf.
- C. The UAP tests the temperature of the water with the wrist before starting.
- D. The UAP collects all the linens and supplies and brings them to the room.
Correct Answer: B
Rationale: Massaging calves (B) risks dislodging a clot in a bedfast client (high DVT risk). Privacy (A), water testing (C), and supplies (D) are appropriate.
The client with varicose veins is six (6) hours postoperative vein ligation. Which nursing intervention should the nurse implement first?
- A. Assist the client to dangle the legs off the side of the bed.
- B. Assess and maintain pressure bandages on the affected leg.
- C. Apply a sequential compression device to the affected leg.
- D. Administer the prescribed prophylactic intravenous antibiotic.
Correct Answer: B
Rationale: Assessing/maintaining pressure bandages (B) prevents bleeding post-vein ligation. Dangling (A) is premature, compression devices (C) are secondary, and antibiotics (D) follow assessment.
Which diagnostic test should the nurse expect for a client with suspected pericarditis?
- A. Electrocardiogram (ECG)
- B. Complete blood count (CBC)
- C. D-dimer test
- D. Chest X-ray
Correct Answer: A
Rationale: An ECG can show characteristic ST-segment elevation in pericarditis due to pericardial inflammation.