A nurse receives report on four clients at the beginning of the shift. Which of the following clients should the nurse place priority on assessing first?
A client who had a myocardial infarction two days ago, and complains of soft stools after taking docusate sodium.
A client being treated for thrombotic thrombocytopenic purpura (TTP) who has had 120 mL of urine output in the last 12 hours.
A client who was admitted for premature atrial contractions (PACS) and whose most recent blood pressure is 148/89.
A client receiving furosemide for heart failure whose daily weight shows that he has lost 0.5 kg since yesterday.
The Correct Answer is B
A. While soft stools after taking docusate sodium is noteworthy, it is not immediately life-threatening and does not require urgent intervention.
B. Oliguria (low urine output) in a client with TTP is concerning because it may indicate acute kidney injury or worsening of the condition, requiring immediate assessment and intervention.
C. An elevated blood pressure in a client with PACs is important but not as critical as potential kidney dysfunction in the TTP patient.
D. A weight loss of 0.5 kg in a client with heart failure on furosemide may be expected and does not require immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Jugular vein distention (JVD) is more commonly associated with right-sided heart failure, not left-sided heart failure.
B. Peripheral edema is also more commonly associated with right-sided heart failure.
C. Ascites or fluid accumulation in the abdomen is typically associated with right-sided heart failure.
D. Pink, frothy sputum is indicative of pulmonary edema, which is a common symptom of left-sided heart failure due to the backup of blood into the lungs.
Correct Answer is D
Explanation
A. Heart transplantation is not indicated for atrial flutter; it is reserved for end-stage heart failure or severe cardiac conditions that cannot be managed by other means.
B. Defibrillation is used in emergency situations for life-threatening arrhythmias like ventricular fibrillation, not for atrial flutter.
C. Coronary artery stent placement is used to open blocked coronary arteries, not to treat arrhythmias.
D. Radiofrequency catheter ablation targets and destroys the abnormal conduction pathways causing atrial flutter, providing a more permanent solution when medications are ineffective.
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