Question

A nurse is collecting data on a client who has infective endocarditis. The nurse should recognize which of the following findings is the priority to report to the provider?

Answer 1

Correct Answers:

Dyspnea

Rationale :

🔷 Dyspnea signals possible heart failure or pulmonary embolism, both life-threatening complications of infective endocarditis.

🔷 It indicates impaired cardiac function or embolic events requiring immediate intervention.

🔷 Prompt reporting allows for rapid diagnostic evaluation and treatment, improving outcomes.

🔷 Symptoms like malaise, fever, or anorexia are expected but not acutely life-threatening.

🔷 Dyspnea is an emergency red flag for deterioration in these clients.

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Answer 2

Correct Answers:

Obtain a pair of slipper socks for the client.

Rationale :

♦ Slipper socks provide warmth and improve circulatory comfort without risk of skin injury.

♦ They are safe for clients with vascular compromise, who may have decreased sensation.

♦ Heating pads or rubbing increase risk for burns or skin damage.

♦ Promotes restful sleep by reducing discomfort from cold extremities.

♦ Non-invasive comfort measures are always preferred first.

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Answer 3

Correct Answers:

The stockings prevent venous stasis.

Rationale :

◾ Antiembolism stockings help prevent blood pooling in the legs, lowering DVT risk.

◾ They encourage venous return to the heart, reducing clot formation.

◾ They do not replace the need for movement or exercises.

◾ Preventing venous stasis is their primary purpose post-surgery.

◾ This teaching helps clients understand the stockings’ vital role.

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Answer 4

Correct Answers:

Dull, aching calf pain

Rationale :

⬛ Dull, aching calf pain is a classic sign of deep vein thrombosis (DVT).

⬛ Pain often worsens with walking or flexion.

⬛ Early recognition is critical to prevent embolism or complications.

⬛ Swelling, warmth, and redness may also be present.

⬛ Reporting pain ensures rapid evaluation and intervention.

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Answer 5

Correct Answers:

"Heparin prevents new cloth from forming rather than dissolving established clots."

Rationale :

❖ Heparin acts by inhibiting clot formation, not by dissolving existing clots.

❖ The body naturally dissolves clots over time via fibrinolysis.

❖ Prevents extension of clots and reduces risk of embolism.

❖ Patients often misunderstand the drug’s action, so clear education is needed.

❖ Understanding this prevents unrealistic expectations and anxiety.

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Answer 6

Correct Answers:

Dyspnea on exertion

Rationale :

⬖ Mitral stenosis impairs blood flow, causing pulmonary congestion and exertional dyspnea.

⬖ Narrowed valve leads to pressure buildup in the lungs.

⬖ Shortness of breath is often the first and most common symptom.

⬖ Early symptom identification improves management and quality of life.

⬖ S3 or S4 sounds are less specific for early mitral stenosis.

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Answer 7

Correct Answers:

Instruct the client to call 911.

Rationale :

✦ Unrelieved chest pain after nitroglycerin may signal myocardial infarction.

✦ Emergency medical help is needed to prevent cardiac arrest or damage.

✦ Delay in care increases risk of serious complications or death.

✦ Nurses must prioritize rapid access to emergency services in such scenarios.

✦ Triage over the phone should always err on the side of caution with chest pain.

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Answer 8

Correct Answers:

Troponin T

Rationale :

⬢ Troponin T remains elevated for 10–14 days after myocardial infarction.

⬢ It is highly specific for cardiac muscle injury.

⬢ CK-MB and myoglobin normalize within 2–3 days.

⬢ Serial troponin measurement helps track recovery or reinjury.

⬢ Persistent elevation guides ongoing cardiac care.

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Answer 9

Correct Answers:

Oxygen

Rationale :

◆ Oxygen is given first to improve tissue perfusion during MI.

◆ Adequate oxygenation is vital for heart and organ survival.

◆ Pain and other interventions follow stabilization of airway and breathing.

◆ Immediate administration reduces extent of cardiac damage.

◆ Always address ABCs (airway, breathing, circulation) first in emergencies.

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Answer 10

Correct Answers:

Beans

Rationale :

◈ Beans are high in fiber, low in cholesterol, and heart-healthy.

◈ They provide protein without saturated fat found in animal products.

◈ Avoid high-cholesterol foods like egg yolks, whole milk, and organ meats.

◈ Beans help control cholesterol levels post-surgery.

◈ This food choice aligns with cardiac dietary guidelines.

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QLexNursing

1 :
A nurse is collecting data on a client who has infective endocarditis. The nurse should recognize which of the following findings is the priority to report to the provider?

2 :
Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

3 :
A nurse is reinforcing teaching with a client following surgery who has antiembolism stockings in place. Which of the following information should the nurse include in the teaching?

4 :
A nurse is caring for a client who is postoperative following vascular surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?

5 :
A nurse is caring for a client who has thrombophlebitis and is receiving a continuous infusion of heparin. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse make?

6 :
A nurse is collecting data from a client who has mitral stenosis. Which of the following findings is a manifestation of this condition?

7 :
A nurse at a provider's office receives a telephone call from a client who reports nausea and has unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse?

8 :
A nurse is reviewing the laboratory findings of a client who experienced an acute myocardial infarction 6 days ago. Which of the following laboratory values should the nurse expect to remain elevated at this time?

9 :
A nurse is caring for a patient who has a suspected myocardial infarction. Which of the following should the nurse administer first?

10 :
A nurse is reinforcing teaching with a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following food choices reflects the client's understanding of these dietary instructions?

QLexNursing

1 : A nurse is collecting data on a client who has infective endocarditis. The nurse should recognize which of the following findings is the priority to report to the provider?

2 : Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

3 : A nurse is reinforcing teaching with a client following surgery who has antiembolism stockings in place. Which of the following information should the nurse include in the teaching?

4 : A nurse is caring for a client who is postoperative following vascular surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?

5 : A nurse is caring for a client who has thrombophlebitis and is receiving a continuous infusion of heparin. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse make?

6 : A nurse is collecting data from a client who has mitral stenosis. Which of the following findings is a manifestation of this condition?

7 : A nurse at a provider's office receives a telephone call from a client who reports nausea and has unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse?

8 : A nurse is reviewing the laboratory findings of a client who experienced an acute myocardial infarction 6 days ago. Which of the following laboratory values should the nurse expect to remain elevated at this time?

9 : A nurse is caring for a patient who has a suspected myocardial infarction. Which of the following should the nurse administer first?

10 : A nurse is reinforcing teaching with a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following food choices reflects the client's understanding of these dietary instructions?

1 :
A nurse is collecting data on a client who has infective endocarditis. The nurse should recognize which of the following findings is the priority to report to the provider?

2 :
Following admission, a client with a vascular occlusion of the right lower extremity calls the nurse and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

3 :
A nurse is reinforcing teaching with a client following surgery who has antiembolism stockings in place. Which of the following information should the nurse include in the teaching?

4 :
A nurse is caring for a client who is postoperative following vascular surgery. Which of the following manifestations should indicate to the nurse that the client has developed a thrombus?

5 :
A nurse is caring for a client who has thrombophlebitis and is receiving a continuous infusion of heparin. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse make?

6 :
A nurse is collecting data from a client who has mitral stenosis. Which of the following findings is a manifestation of this condition?

7 :
A nurse at a provider's office receives a telephone call from a client who reports nausea and has unrelieved chest pain after taking a nitroglycerin tablet 5 min ago. Which of the following is an appropriate response by the nurse?

8 :
A nurse is reviewing the laboratory findings of a client who experienced an acute myocardial infarction 6 days ago. Which of the following laboratory values should the nurse expect to remain elevated at this time?

9 :
A nurse is caring for a patient who has a suspected myocardial infarction. Which of the following should the nurse administer first?

10 :
A nurse is reinforcing teaching with a client about following a low-cholesterol diet after coronary artery bypass grafting. Which of the following food choices reflects the client's understanding of these dietary instructions?