A client with heart failure (HF) is waiting in the preoperative area for a scheduled procedure and tells the nurse, "My heart feels like it is beating too fast and I feel faint." After initiating a call for an electrocardiogram (ECG), which assessment data is most important for the nurse to obtain?

Degree of skin elasticity.

Length of capillary refill.

Rhythm of apical pulse.

Volume of pedal pulses.

Answer and Explanation

The Correct Answer is C

Choice A reason: The degree of skin elasticity is a measure often used to assess hydration status, especially in older adults. However, it does not provide direct information about the client's cardiac function or the cause of their current symptoms.

Choice B reason: The length of capillary refill is useful for assessing peripheral perfusion and overall circulatory status. While prolonged capillary refill can indicate poor perfusion, it does not provide specific information about heart rhythm or the cause of palpitations and faintness in a client with heart failure.

Choice C reason: The rhythm of the apical pulse is the most important assessment data to obtain in this scenario. The client's complaint of a fast-beating heart and feeling faint suggests a possible arrhythmia, which could be detected by assessing the rhythm of the apical pulse. This assessment can help identify irregular heartbeats, tachycardia, or other abnormalities that may require immediate intervention.

Choice D reason: The volume of pedal pulses can provide information about peripheral circulation, but it is not as crucial as assessing the heart rhythm in a client experiencing palpitations and faintness. Peripheral pulse volume may not change significantly with certain arrhythmias or cardiac issues that affect the central circulation more directly.

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Correct Answer is B

Explanation

Choice A reason: Petechial haemorrhage under the client's eyes can be a sign of various conditions, including increased intrathoracic pressure from vomiting. However, it is not the most urgent finding in this scenario. The nurse should focus on the finding that indicates a potential life-threatening condition.

Choice B reason: Right lower abdomen rebound tenderness is a sign of peritonitis, which can be caused by appendicitis or other serious abdominal conditions. This is an urgent finding that requires immediate medical attention, as it indicates inflammation of the peritoneum and potential risk of perforation or severe infection.

Choice C reason: Severe headache with photosensitivity can be associated with conditions such as meningitis or migraines. While concerning, it does not take precedence over the abdominal signs that indicate a potentially life-threatening condition like peritonitis.

Choice D reason: Dark green coloured emesis can be indicative of bile or upper gastrointestinal content, which might be seen in conditions such as intestinal obstruction or vomiting. However, it is not as urgent as the finding of rebound tenderness, which suggests an acute and severe abdominal condition that needs immediate intervention.

A. Alopecia. B. Haematuria. C. Fatigue. D. Joint pain.

Correct Answer is B

Explanation

Choice A reason: Alopecia, or hair loss, is a common symptom of systemic lupus erythematosus but does not require immediate follow-up. It is not life-threatening and can be managed as part of the overall treatment plan.

Choice B reason: Haematuria, or blood in the urine, requires immediate follow-up because it can indicate serious renal involvement or a possible flare-up of lupus nephritis. Kidney complications in lupus can lead to severe outcomes if not addressed promptly.

Choice C reason: Fatigue is a common symptom of lupus and while it can significantly impact the client's quality of life, it does not usually require urgent intervention. It is managed through ongoing treatment and lifestyle adjustments.

Choice D reason: Joint pain is another common symptom of lupus. Although it can be debilitating, it is not an emergency and can be managed through standard treatments for lupus.

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A client with heart failure (HF) is waiting in the preoperative area for a scheduled procedure and tells the nurse, "My heart feels like it is beating too fast and I feel faint." After initiating a call for an electrocardiogram (ECG), which assessment data is most important for the nurse to obtain?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse completes the admission assessment of a client with systemic lupus erythematosus. Which finding requires immediate follow-up by the nurse?

Correct Answer is B

Explanation

A client is newly diagnosed with type 2 diabetes mellitus. The nurse is educating the client about self-monitoring blood glucose (SMBG) and haemoglobin A1C. Which statement by the client indicates teaching has been effective?

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