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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?
- A. Flank pain with radiation to the groin, accompanied by hematuria.
- B. Respiratory distress, chest pain, and use of accessory muscles.
- C. Crackles, peripheral edema, and weight gain.
- D. Confusion, decreasing level of consciousness, and aphasia.
Correct Answer: C
Rationale: The correct answer is C: Crackles, peripheral edema, and weight gain. In infective endocarditis, there is a risk of developing heart failure due to damage to the heart valves. Monitoring for crackles indicates fluid accumulation in the lungs, a sign of left-sided heart failure. Peripheral edema is a result of right-sided heart failure, which can occur in infective endocarditis. Weight gain is a common symptom of heart failure due to fluid retention. Flank pain with radiation to the groin and hematuria (choice A) are more indicative of kidney issues rather than heart failure. Respiratory distress, chest pain, and use of accessory muscles (choice B) are more suggestive of acute pulmonary conditions. Confusion, decreasing level of consciousness, and aphasia (choice D) are symptoms of neurological issues, not heart failure.
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A nurse is caring for a client. Select the 5 findings that can cause delayed wound healing.
- A. Potassium level.
- B. Prealbumin level.
- C. History of diabetes mellitus.
- D. History of hyperlipidemia.
- E. Wound infection.
- F. Decreased pedal perfusion.
- G. Fasting blood glucose.
Correct Answer: B,C,E,F,G
Rationale: The correct answer choices (B, C, E, F, G) can cause delayed wound healing due to specific reasons.
B: Prealbumin level reflects protein status, crucial for wound healing.
C: Diabetes mellitus impairs circulation and immune response, affecting healing.
E: Wound infection introduces pathogens, prolonging inflammation and delaying healing.
F: Decreased pedal perfusion reduces oxygen and nutrient delivery to the wound site.
G: Elevated fasting blood glucose hinders immune cell function and collagen synthesis.
Incorrect choices (A, D) are not directly linked to wound healing delays. Potassium level (A) mainly affects cardiac and muscle function, and hyperlipidemia (D) primarily impacts cardiovascular health, not wound healing directly.
A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his face, chest, abdomen, and upper arms. What is the nurse’s priority intervention for this client during the resuscitation phase of injury?
- A. Medicate for pain.
- B. Maintain the airway.
- C. Insert an indwelling urinary catheter.
- D. Initiate fluid resuscitation.
Correct Answer: B
Rationale: The correct answer is B: Maintain the airway. During the resuscitation phase of burn injuries, priority is given to ensuring airway patency to prevent respiratory distress and failure. Burns to the face, chest, and abdomen can lead to airway compromise due to swelling and damage. Maintaining the airway is crucial to ensure adequate oxygenation and ventilation. Pain management (choice A) is important but not the priority in this phase. Inserting a urinary catheter (choice C) is not a priority during the resuscitation phase. Initiating fluid resuscitation (choice D) is important but only after ensuring airway patency.
A nurse is admitting a client who has sustained severe burn injuries in a grease fire. Using the Rule of Nines, the nurse should estimate that the client has burned the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.
Correct Answer: 72
Rationale: The Rule of Nines is a method used to estimate the total body surface area (TBSA) burned in a patient with severe burns. According to this rule, each major body part represents a specific percentage of the TBSA. In an adult, the head accounts for 9%, each upper extremity is 9% (18% total), the front of the trunk is 18%, the back of the trunk is 18%, each lower extremity is 18% (36% total), and the genital area is 1%. Therefore, if a client has sustained severe burn injuries in a grease fire, the nurse should estimate that the client has burned approximately 72% of their TBSA. This calculation is crucial in determining the severity of the burns and guiding appropriate treatment. The correct answer is 72 because it reflects the accurate estimation of the TBSA burned using the Rule of Nines. The other choices are incorrect as they do not align with the standard percentages
A nurse is assessing a client who has cirrhosis. Which of the following is an expected finding for this client?
- A. Moist skin.
- B. Blood in the urine.
- C. Spider angiomas.
- D. Tarry stools.
Correct Answer: C
Rationale: The correct answer is C: Spider angiomas. In cirrhosis, the liver is damaged leading to increased pressure in the portal vein. This results in dilated blood vessels on the skin surface known as spider angiomas. This finding is expected due to the liver's inability to process blood effectively. Choice A (Moist skin) is incorrect as cirrhosis commonly causes dry and itchy skin. Choice B (Blood in the urine) is incorrect because cirrhosis typically does not directly affect the kidneys. Choice D (Tarry stools) is incorrect as it is a symptom of gastrointestinal bleeding, which can occur in cirrhosis but is not a specific finding.
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication?
- A. Friction rub.
- B. Intermittent claudication.
- C. Cardiac murmur.
- D. Dependent rubor.
Correct Answer: C
Rationale: The correct answer is C: Cardiac murmur. Endocarditis is an infection of the inner lining of the heart chambers and valves, which can lead to the development of a new murmur due to valve damage or vegetation formation. This can result in turbulent blood flow, causing the murmur. A friction rub (choice A) is more indicative of pericarditis, intermittent claudication (choice B) is associated with peripheral arterial disease, and dependent rubor (choice D) is seen in chronic arterial insufficiency. Therefore, recognizing a new cardiac murmur in a client with endocarditis is crucial as it can indicate complications such as valve dysfunction or embolic events.