After receiving a change-of-shift report about the following four patients on the cardiac care unit, which patient would the nurse assess first?.
A 65-year-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about today's planned discharge.
A 59-year-old patient with unstable angina who has just returned after a percutaneous coronary intervention (PCI).
A 56-year-old patient with variant angina who is scheduled to receive nifedipine (Procardia).
A 39-year-old patient with pericarditis who is complaining of sharp, stabbing chest pain.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E","G","H"]
Explanation
Choice A rationale:
The apical pulse rate increased from 90/min to 112/min, which is still within the normal range (60-100 beats per minute). Therefore, it’s not a critical change.
Choice B rationale:
The adolescent’s position, supine with legs straight, is the recommended position after cardiac catheterization to prevent bleeding from the femoral artery puncture site.
Choice C rationale:
The pulses of the right extremity decreased to 2+, indicating reduced blood flow. This is a critical finding and should be reported.
Choice D rationale:
The pain increased from 0 to 2 on a scale of 0 to 10. While any increase in pain should be monitored, a score of 2 is not typically considered severe.
Choice E rationale:
The pressure dressing became saturated with bloody drainage, indicating possible bleeding. This is a critical finding and should be reported.
Choice F rationale:
The respiratory rate increased from 16/min to 18/min, which is still within the normal range (12-20 breaths per minute). Therefore, it’s not a critical change.
Choice G rationale:
The blood pressure decreased from 120/76 mm Hg to 100/52 mm Hg. A significant drop in blood pressure can indicate blood loss or shock. This is a critical finding and should be reported.
Choice H rationale:
The right lower extremity became cool and pale, indicating reduced blood flow. This is a critical finding and should be reported.
So, the correct answer is Choice C, E, G, H, after analyzing all choices. .
Correct Answer is A
Explanation
Choice A rationale:
An increase in heart rate from 66 to 98 beats/min indicates that the heart is working harder, which could be a sign of stress or exertion. This is a significant increase and could indicate that the patient needs to rest.
Choice B rationale:
While a drop in O2 saturation from 99% to 95% is noticeable, it is still within the normal range (95-100%). Therefore, it would not necessarily indicate a need for the patient to rest.
Choice C rationale:
A respiratory rate increase from 14 to 20 breaths/min is within the normal range (12-20 breaths/min) and would not necessarily indicate a need for the patient to rest.
Choice D rationale:
A blood pressure change from 118/60 to 126/68 mm Hg is within the normal range and would not necessarily indicate a need for the patient to rest.
So, the correct answer is Choice A, after analyzing all choices.
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