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 D
Explanation
Choice A rationale:
The pain level of 3 to 5 on a scale of 0 to 10 does not specifically indicate chronic stable angina.
Choice B rationale:
Pain that has worsened over the last week could indicate a number of conditions, not specifically chronic stable angina.
Choice C rationale:
Pain that wakes a patient up at night could be a sign of a number of conditions, not specifically chronic stable angina.
Choice D rationale:
Chronic stable angina is characterized by chest pain that is relieved by rest or nitroglycerin. Therefore, if the patient’s pain goes away with a nitroglycerin tablet, it would help confirm a diagnosis of chronic stable angina.
So, the correct answer is Choice D, after analyzing all choices.
Correct Answer is A
Explanation
Choice A rationale:
Elevated troponin is a sign of heart damage, which could be caused by a heart attack or other stresses on the heart. This is a critical finding that needs immediate attention.
Choice B rationale:
Q waves on an ECG can indicate a previous heart attack or myocardial infarction. However, they can also be a normal variant, meaning they are a harmless variation in the electrical activity of the heart.
Choice C rationale:
Bilateral crackles in the lungs can indicate mucus or fluid in the base of the lungs, often associated with conditions like pneumonia, heart failure, or bronchitis.
Choice D rationale:
Hyperglycemia, or high blood glucose, can be a sign of diabetes. If untreated, it can lead to serious complications like ketoacidosis.
So, the correct answer is Choice A, after analyzing all choices.
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