A patient who has chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action would the nurse take first?.
Auscultate the breath sounds.
Check the capillary refill.
Auscultate the abdomen.
Ask about the patient's allergies.
The Correct Answer is A
Choice A rationale:
In a patient with severe dyspnea and a dry, hacking cough, auscultating the breath sounds would be the first action to assess for any abnormalities.
Choice B rationale:
Checking the capillary refill would not be the first action as it does not directly relate to the symptoms of severe dyspnea and a dry, hacking cough.
Choice C rationale:
Auscultating the abdomen would not be the first action as it does not directly relate to the symptoms of severe dyspnea and a dry, hacking cough.
Choice D rationale:
Asking about the patient’s allergies would not be the first action as it does not directly relate to the symptoms of severe dyspnea and a dry, hacking cough.
So, the correct answer is A, after analyzing all choices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A weight increase from 120 pounds to 122 pounds over 3 days is within the normal fluctuation range.
Choice B rationale:
A serum potassium level of 3.0 mEq/L after 1 week of therapy is concerning because it’s below the normal range (3.5-5.0 mEq/L)171819. This could indicate hypokalemia, which can cause serious complications if left untreated.
Choice C rationale:
A palpable liver edge 2 cm below the ribs on the right side could suggest an abnormality such as an enlarged liver.
Choice D rationale:
The presence of 1+ to 2+ edema in the feet and ankles could indicate conditions like heart failure or venous insufficiency.
So, the correct answer is Choice B, after analyzing all choices.
Correct Answer is B
Explanation
Choice A rationale:
A patient who had a myocardial infarction (MI) 4 days ago and is anxious about today’s planned discharge would need reassurance and education, but it’s not an immediate concern.
Choice B rationale:
A patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI) is at risk for hemorrhage from the arterial access site. Immediate assessment of blood pressure, pulses, and the access site is required.
Choice C rationale:
A patient with variant angina who is scheduled to receive nifedipine (Procardia) would need monitoring, but it’s not the most urgent.
Choice D rationale:
A patient with pericarditis complaining of sharp, stabbing chest pain would need evaluation, but the risk of complications is less immediate than for Choice B1.
So, the correct answer is B, after analyzing all choices.
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