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 A
Explanation
A. This statement indicates a lack of understanding about hidden sodium in restaurant foods. Many restaurant dishes contain high levels of sodium, even if additional salt is not added at the table. The client needs to be educated about choosing low-sodium options when dining out and asking about the sodium content of meals.
B. This statement reflects correct understanding, as fresh vegetables typically contain less sodium than canned vegetables, which often have added salt.
C. This statement shows proper knowledge, as reading nutrition labels helps identify foods with high sodium content, allowing for better dietary choices.
D. This statement is appropriate, as using lemon juice and herbs is a good alternative to adding salt for flavoring food.
Correct Answer is A
Explanation
A. Transporting the patient to the cardiac catheterization lab for percutaneous coronary intervention (PCI) is the priority intervention for a patient with an ST-elevation myocardial infarction (STEMI). PCI is the preferred treatment to restore blood flow to the affected coronary artery.
B. Aggressive diuresis and digoxin are not appropriate for the acute management of a STEMI. Diuresis may be used in cases of heart failure but is not the immediate priority.
C. Synchronized cardioversion and radiofrequency catheter ablation are treatments for certain arrhythmias but are not indicated for the acute management of STEMI.
D. Administering gemfibrozil, a lipid-lowering agent, and preparing for a stress test are not appropriate interventions in the acute setting of a STEMI. Immediate reperfusion therapy is necessary.
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