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","D","F","G"]
Explanation
A. Administering furosemide 40 mg via IV push once is appropriate for treating fluid overload, as evidenced by pitting edema and crackles in the lungs, common in heart failure.
B. An IV infusion of normal saline (NS) at 150 mL/hr is not appropriate for this client as it can exacerbate fluid overload and worsen heart failure symptoms.
C. Administering digoxin 0.25 mg via IV push NOW may be indicated, but considering the client's low pulse rate (55/min), caution is necessary due to the risk of digoxin toxicity and bradycardia.
D. Monitoring daily weights is crucial for assessing fluid balance in heart failure patients and detecting any changes in fluid status.
E. Calling a code STEMI is not appropriate as the client does not exhibit signs of a STEMI; troponin levels are not elevated, and there is no indication of an acute myocardial infarction.
F. Monitoring strict intake and output helps in managing fluid balance and ensuring accurate assessment of the client's fluid status.
G. Preparing the client for an echocardiogram is appropriate to assess cardiac function and evaluate the severity of heart failure.
H. Radiofrequency catheter ablation is not indicated for this client as it is typically used to treat arrhythmias, not heart failure or fluid overload.
Correct Answer is B
Explanation
A. Plasmapheresis in TTP aims to remove abnormal blood components, not ADAMTS-13. In fact, plasmapheresis helps replenish ADAMTS-13.
B. The primary goal of plasmapheresis in TTP is to remove large von Willebrand factor molecules that are causing platelet aggregation and clot formation.
C. Removing macrophages from the spleen is not the objective of plasmapheresis.
D. Plasmapheresis is usually performed daily until clinical and laboratory parameters improve, not just once a week.
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