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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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. "Did you take aspirin today?". B. "Do you have any allergies?". C. "Can you rate the pain on a 0 to 10 scale?". D. "What time did your pain begin?". .

Correct Answer is D

Explanation

Choice A rationale:

While aspirin is often given to patients with suspected myocardial infarction, asking if the patient took aspirin does not help determine the timing of the onset of symptoms.

Choice B rationale:

Knowing the patient’s allergies is important for medication safety, but it does not help determine eligibility for thrombolytic therapy.

Choice C rationale:

Rating the pain on a scale helps assess the severity of the pain, but it does not provide information about the timing of the onset of symptoms.

Choice D rationale:

The time of pain onset is crucial in determining eligibility for thrombolytic therapy. Thrombolytic therapy is most effective when given within a certain time frame from the onset of symptoms.

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

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

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?.

Correct Answer is D

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

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

A nurse is supervising a new graduate who is providing discharge teaching to a patient diagnosed with hypertension. While teaching a patient about their newly prescribed diuretic (furosemide), which of the following statements made by the new graduate requires correction by the supervising nurse?.

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

The nurse is assessing a patient with myocarditis before giving a scheduled dose of digoxin (Lanoxin). Which finding is most important for the nurse to communicate to the health care provider?.

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