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

Patient with dilated cardiomyopathy who has bilateral crackles at the lung bases.

Patient with acute aortic regurgitation whose blood pressure is 86/54 mm Hg.

Patient with infective endocarditis who has a murmur and splinter hemorrhages.

Patient with rheumatic fever who has sharp chest pain with a deep breath.

Answer and Explanation

The Correct Answer is B

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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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. .

A. Auscultate the breath sounds. B. Check the capillary refill. C. Auscultate the abdomen. D. Ask about the patient's allergies.

Correct Answer is A

Explanation

Choice A rationale:

In a patient with severe dyspnea and a dry, hacking cough, auscultating the breath sounds would be the first action to assess for any abnormalities.

Choice B rationale:

Checking the capillary refill would not be the first action as it does not directly relate to the symptoms of severe dyspnea and a dry, hacking cough.

Choice C rationale:

Auscultating the abdomen would not be the first action as it does not directly relate to the symptoms of severe dyspnea and a dry, hacking cough.

Choice D rationale:

Asking about the patient’s allergies would not be the first action as it does not directly relate to the symptoms of severe dyspnea and a dry, hacking cough.

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

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.

Correct Answer is ["C","E","G","H"]

Explanation

A patient who has chronic heart failure is admitted to the emergency department with severe dyspnea and a dry, hacking cough. Which action would the nurse take first?.

Correct Answer is A

Explanation

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

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