A patient with a recent exacerbation of heart failure is feeling uncomfortable and anxious, with a sensation of flopping in the chest.
While waiting for an electrocardiogram (ECG), which assessment should the nurse prioritize?
Rhythm of the apical pulse.
Volume of pedal pulses.
Degree of skin elasticity.
Length of capillary refill.
The Correct Answer is A
Choice A rationale
In a patient with a recent exacerbation of heart failure who is feeling uncomfortable and anxious, with a sensation of flopping in the chest, the rhythm of the apical pulse should be prioritized. This is because changes in heart rhythm can indicate worsening heart failure or other serious cardiac conditions.
Choice B rationale
While the volume of pedal pulses can provide information about peripheral circulation, it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.
Choice C rationale
The degree of skin elasticity can provide information about hydration status, but it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.
Choice D rationale
The length of capillary refill can provide information about peripheral circulation and overall cardiovascular status, but it is not as immediately relevant as the rhythm of the apical pulse in a patient with heart failure experiencing discomfort and anxiety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A client with a positive Mantoux test and sputum cultures positive for acid-fast bacillus (AFB) is indicative of tuberculosis, an airborne disease. This client would require a room with negative airflow, use of a particulate respirator mask, and adherence to airborne as well as standard precautions.
Choice B rationale
Scabies is a skin infestation caused by a mite. It is transmitted through direct skin-to-skin contact and does not require airborne precautions.
Choice C rationale
Scarlet fever is a bacterial illness that often presents with a rash and is associated with strep throat. It is spread by direct contact with mucus, saliva, or skin sores of a person infected with the bacteria. It does not require airborne precautions.
Choice D rationale
Herpes simplex II lesions are typically sexually transmitted and do not require airborne precautions. Standard precautions would be sufficient.
Correct Answer is D
Explanation
Choice A rationale
Diaphragmatic respirations are normal in infants and do not necessarily indicate acute respiratory distress.
Choice B rationale
A resting respiratory rate of 35 breaths/min is within the normal range for a 4-month-old infant and does not necessarily indicate acute respiratory distress.
Choice C rationale
Bilateral bronchial breath sounds are normal findings and do not necessarily indicate acute respiratory distress.
Choice D rationale
Flaring of the nares, or nostrils, is a sign of respiratory distress in children. It indicates that the child is having to work harder to breathe.
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