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 A
Explanation
Choice A rationale:
An irregular pulse could indicate that myocarditis is affecting the heart’s electrical system, leading to an irregular heartbeat or arrhythmia. This could potentially affect the action of digoxin, a medication used to treat heart conditions, and therefore should be communicated to the healthcare provider.
Choice B rationale:
Leukocytosis, or a high white blood cell count, can be a sign of infection or inflammation, including myocarditis. However, it is not as specific as an irregular pulse in indicating a potential issue with the administration of digoxin.
Choice C rationale:
Generalized myalgia, or muscle pain, can be a symptom of myocarditis. However, it is not as directly related to the action of digoxin as an irregular pulse.
Choice D rationale:
Fatigue can be a symptom of myocarditis. However, it is not as directly related to the action of digoxin as an irregular pulse.
So, the correct answer is A, after analyzing all choices.
Correct Answer is D
Explanation
Choice A rationale:
The right upper-sternal border is not the best place to hear a murmur typical of mitral regurgitation.
Choice B rationale:
The left upper-sternal border is not the best place to hear a murmur typical of mitral regurgitation.
Choice C rationale:
The left lower-sternal border is not the best place to hear a murmur typical of mitral regurgitation.
Choice D rationale:
The apex of the heart is the best place to hear a murmur typical of mitral regurgitation. This is where the sound will be most audible.
So, the correct answer is Choice D, after analyzing all choices.
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