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 ["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. .

A. A brief episode of ventricular tachycardia. B. Bleeding from the gums. C. Decreased level of consciousness. D. An increase in blood pressure.

Correct Answer is B

Explanation

Choice A rationale:

A brief episode of ventricular tachycardia, or a rapid heart rate, can occur in patients receiving thrombolytic therapy. However, it is not typically a reason to stop the drug infusion.

Choice B rationale:

Bleeding from the gums can be a sign of excessive bleeding, which is a major risk of thrombolytic therapy. This would be a reason to stop the drug infusion.

Choice C rationale:

A decreased level of consciousness can have many causes and is not specifically associated with thrombolytic therapy.

Choice D rationale:

An increase in blood pressure is not typically a reason to stop thrombolytic therapy.

So, the correct answer is B, 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

Correct Answer is ["B","E"]

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?.

Correct Answer is B

Explanation

After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information is most important for the nurse to communicate to the health care 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 has pain due to acute pericarditis. Which action would the nurse take?.

A patient with a history of hypertension arrives in the emergency department with a blood pressure (BP) reading of 213/126 mm Hg. The patient has a history of drug abuse. Which of the following initial questions posed by the nurse is MOST appropriate?.

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?.

The nurse obtains a health history from an older adult with a prosthetic mitral valve who has symptoms of infective endocarditis (IE). Which question by the nurse helps identify a risk factor for IE?.

A patient who has recently had an acute myocardial infarction (AMI) ambulates in the hospital hallway. Which data would indicate to the nurse that the patient should stop and rest?.

In preparation for discharge, the nurse teaches a patient with chronic stable angina how to use the prescribed short-acting and long-acting nitrates. Which patient statement indicates that the teaching has been effective?.