which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 5

1. Which potential complication should the nurse assess for in the client with infective endocarditis who has embolization of vegetative lesions from the mitral valve?

Correct answer: B

Rationale: The correct answer is B: Decreased urine output. When vegetative lesions from the mitral valve embolize, they can block blood flow to the kidneys, leading to renal infarction. This can result in decreased urine output. Choices A, C, and D are incorrect. Pulmonary embolism involves a blockage of an artery in the lungs, not directly related to embolization from the mitral valve. Hemoptysis is the coughing up of blood from the respiratory tract, which is not a direct consequence of embolization from the mitral valve. Deep vein thrombosis is the formation of a blood clot in a deep vein, unrelated to embolization from the mitral valve.

2. The nurse is caring for a client who goes into ventricular tachycardia. Which intervention should the nurse implement first?

Correct answer: B

Rationale: The correct answer is to assess the client for a pulse. In ventricular tachycardia, the priority is to determine if the client has a pulse. If there is no pulse, immediate initiation of CPR with chest compressions is required. Calling a code or continuing to monitor the client can delay life-saving interventions. Therefore, assessing for a pulse is the most crucial step in managing ventricular tachycardia.

3. A patient taking anticoagulants should be cautious about consuming which type of food?

Correct answer: C

Rationale: The correct answer is C: High-vitamin K foods. Foods high in vitamin K can interfere with the effectiveness of anticoagulants. Vitamin K plays a crucial role in blood clotting, so consuming high amounts of it can counteract the anticoagulant effects. Choices A, B, and D are incorrect as they do not directly interfere with the action of anticoagulants.

4. In assessing the client's chest, which position best shows chest expansion as well as its movements?

Correct answer: A

Rationale: The position that best shows chest expansion as well as its movements is when the client is sitting. When the client is seated, their chest is in an optimal position for observing the full range of chest expansion during breathing. This position allows for easy visualization of chest movements and expansion as the client breathes in and out, providing a comprehensive assessment of respiratory function. Choice B (Prone) and Choice D (Supine) involve positions where the chest's movements and expansion are less visible and may not provide an accurate representation of respiratory function. Choice C (Sidelying) can also limit the visibility of chest expansion compared to the sitting position.

5. What is the primary goal of care for a client diagnosed with sickle cell anemia?

Correct answer: C

Rationale: The primary goal of care for a client diagnosed with sickle cell anemia is to help them live as normal a life as possible. This involves managing symptoms, preventing crises, and promoting overall well-being. While options A, B, and D are important aspects of care, the ultimate goal is to enhance the client's quality of life and support them in leading a fulfilling and active lifestyle despite their condition.

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