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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Teaching the patient to take deep, slow breaths might not be effective in controlling the pain due to acute pericarditis.

Choice B rationale:

Placing the patient in Fowler’s position, leaning forward on the table, can help relieve the pain associated with acute pericarditis.

Choice C rationale:

Forcing fluids to 3000 mL/day to decrease inflammation is not a recommended action for managing pain due to acute pericarditis.

Choice D rationale:

Providing a fresh ice bag every hour for the patient to place on the chest is not a recommended action for managing pain due to acute pericarditis.

So, the correct answer is B, after analyzing all choices.

A. Patient with dilated cardiomyopathy who has bilateral crackles at the lung bases. B. Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg. C. Patient with infective endocarditis who has a murmur and splinter hemorrhages. D. Patient with rheumatic fever who has sharp chest pain with a deep breath.

Correct Answer is B

Explanation

Choice A rationale:

While bilateral crackles at the lung bases indicate fluid accumulation, a common symptom of dilated cardiomyopathy, it’s not as immediately life-threatening as some other conditions.

Choice B rationale:

Acute aortic regurgitation can lead to a rapid and severe drop in blood pressure, which is a medical emergency. Therefore, this patient should be assessed first.

Choice C rationale:

While a murmur and splinter hemorrhages are symptoms of infective endocarditis, they are not as immediately life-threatening as acute aortic regurgitation.

Choice D rationale:

Sharp chest pain with a deep breath could be a symptom of rheumatic fever, but it’s not as immediately life-threatening as acute aortic regurgitation.

So, the correct answer is Choice B, after analyzing all choices.

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After receiving a change-of-shift report about the following four patients on the cardiac care unit, which patient would the nurse assess first?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has pain due to acute pericarditis. Which action would the nurse take?.

Correct Answer is B

Explanation

After receiving a change-of-shift report on four patients, which patient would the nurse assess first?.

Correct Answer is B

Explanation

The nurse is administering a thrombolytic agent to a patient having an acute myocardial infarction. Which patient data indicates that the nurse should stop the drug infusion?.

A nurse is caring for an adolescent following a cardiac catheterization. Exhibits Which of the following assessment findings should the nurse report to the provider? Select the 4 findings that the nurse should report to the provider.

The nurse is admitting a patient who has chest pain. Which assessment data suggest that the pain may be from an acute myocardial infarction?.

A patient is admitted to the emergency department and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question would the nurse ask to determine whether the patient is a candidate for thrombolytic therapy?.

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While auscultating a patient's heart sounds, a nurse detects a fourth heart sound (S4). The nurse understands that this finding possibly indicates:.

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Which patient statement indicates that the nurse's teaching about sublingual nitroglycerin (Nitrostat) has been effective?.