The nurse is assessing a client with infective endocarditis (IE). Which of the following would be an expected finding? Select all that apply.
A. Fever
B. Night sweats
C. Osler nodes
D. Cardiac murmur
E. Syncope
F. Weight loss - AChoices A, B, C, D, and F are correct. Infective endocarditis (I...
, A
The nurse is assessing a client with infective endocarditis (IE). Which of the following would be
R
an expected finding? Select all that apply.
A. Fever
B. Night sweats
C. Osler nodes
U
D. Cardiac murmur
E. Syncope
F. Weight loss - AChoices A, B, C, D, and F are correct. Infective endocarditis (IE) is a serious
LA
condition that, if untreated, may lead to heart failure. Infectious symptoms are the hallmark of
this condition, including fever, night sweats, chills, weight loss, headache, and malaise. Other
physical manifestations that may be assessed with IE include a cardiac murmur, Janeway
lesions (flat, reddened maculae on hands and feet), Roth spots (hemorrhagic lesions that
appear as round or oval spots on the retina), and Osler nodes (on palms of hands and soles of
feet).
C
The nurse has provided education to a client diagnosed with obstructive sleep apnea (OSA).
Which client statement would indicate a correct understanding of the teaching?
O
A. "I should use an antiseptic mouthwash immediately before going to bed."
B. "I will plan on exercising at least 150 minutes a week."
D
C. "I have been reading about the potential for me needing supplemental oxygen overnight."
D. "I will sleep flat on my bed without any pillows." - Acorrect answer is B
A crucial part of mitigating the symptoms of obstructive sleep apnea is for a client to lose weight.
Weight reduction is a pivotal part of the treatment plan for an individual with OSA, as being
overweight or obese causes fat deposits in the upper airways. Reducing these fat deposits
improves muscle activity and allows for better ventilation. The client stated that they plan on
exercising 150 minutes a week is a favorable response because that is the national
recommendation
, incorrect C: The primary issue with OSA is not low oxygen; the tongue, soft palate, and other
neck muscles relax, causing displacement and obstruction. This impediment causes the client to
retain carbon dioxide, which explains why they have a headache in the morning and do not feel
rested. Low oxygen is also found, but supplemental oxygen is not the remedy, as continuous
positive airway pressure (CPAP) is the gold standard because of its positive pressure. The
positive pressure keeps the upper airways open, allowing gas exchange. The client requires
positive pressure, not oxygen.
When caring for a client with total parenteral nutrition (TPN), what is the most important action
by the nurse?
A
A. Record the number of stools per day
R
B. Maintain strict intake and output records
C. Sterile technique for dressing change at IV site
U
D. Monitor for cardiac arrhythmias - AChoice C is correct. Clients receiving TPN are very
susceptible to infection. The concentrated glucose solutions are an excellent medium for
bacterial growth. Strict sterile technique is crucial in preventing disease at the IV infusion site.
LA
Choices A, B, and D are incorrect. Although these are appropriate nursing interventions, they
are not the essential action of the nurse in this example.
The nurse is caring for a client with a chest tube drainage system. The nurse notes that the fluid
in the water seal column is not fluctuating. The nurse knows that the best explanation of
fluctuation cessation is that:
C
A. There may be fibrin clots in the tubing
B. The lung is collapsing
O
C. There has been an increase in intrapleural pressure
D
D. The tubing may have become dislodged from the chest - AChoice A is correct. Fluctuation in
the water seal column of a chest tube drainage system typically indicates proper functioning of
the system. Cessation of fluctuation may occur due to various reasons, but one common cause
is the presence of fibrin clots in the tubing. Fibrin clots can obstruct the flow of air and fluid
within the tubing, leading to the absence of fluctuation. This situation should be promptly
assessed and addressed to ensure proper drainage and prevent complications. This may also
occur when the lung becomes fully expanded.
Choice B is incorrect. Fluctuation in the water seal column of a chest tube drainage system is a
sign that the lung is re-expanding and that the drainage system is working correctly.
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