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 ["B","E"]
Explanation
Choice A rationale:
Dependent rubor refers to redness of the skin that occurs when the leg is in a dependent (hanging down) position. It is often associated with peripheral artery disease. However, the child’s symptoms do not indicate this condition.
Choice B rationale:
Digitalis toxicity can occur as a result of high levels of the drug digoxin. Symptoms can include nausea, vomiting, weakness, and vision changes. Given that the child has been administered digoxin, there is a risk for this condition.
Choice C rationale:
Carditis is inflammation of the heart or its surroundings. It is usually caused by bacterial or viral infections. The child’s symptoms do not suggest an infection, making this choice less likely.
Choice D rationale:
Hypercyanotic spells, also known as “tet spells,” are associated with Tetralogy of Fallot, a specific congenital heart defect. The child has a history of congenital mitral stenosis, not Tetralogy of Fallot, making this choice less likely.
Choice E rationale:
Hypokalemia, or low potassium levels, can occur as a side effect of taking diuretics like furosemide. Given that the child has been administered furosemide, there is a risk for this condition.
Choice F rationale:
Fever is usually a response to infection or inflammation. The child’s symptoms do not suggest an infection or inflammation, making this choice less likely.
Choice G rationale:
Hypertension, or high blood pressure, is not indicated in the child’s symptoms or history. The child’s blood pressure readings are within normal range, making this choice less likely.
Choice H rationale:
A murmur is a sound that can be heard when listening to the heart with a stethoscope. It is often caused by turbulent blood flow through the heart. The child’s notes do not mention a murmur, making this choice less likely.
So, the correct answer is, the child is at risk for developing Digitalis toxicity and Hypokalemia. .
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