After receiving a change-of-shift report, which patient admitted to the emergency department should the nurse assess first?
A 39-year-old patient who has right calf tenderness and swelling after a plane ride
A 58-year-old patient taking anticoagulants for atrial fibrillation who has black stools
A 67-year-old patient who has a gangrenous foot ulcer with a weak pedal pulse
A 50-year-old patient who is reporting sudden sharp and severe upper back pain .
The Correct Answer is D
Choice A rationale
While calf tenderness and swelling after a plane ride could potentially indicate a deep vein thrombosis, this condition is not immediately life-threatening in most cases. The patient would need evaluation and treatment, but other patients might have more urgent needs14.
Choice B rationale
A patient taking anticoagulants for atrial fibrillation who has black stools could potentially have gastrointestinal bleeding, which would need evaluation. However, this condition might not be immediately life-threatening, and other patients might have more urgent needs14.
Choice C rationale
A patient with a gangrenous foot ulcer and a weak pedal pulse would need evaluation and treatment. However, this condition might not be immediately life-threatening, and other patients might have more urgent needs14.
Choice D rationale
A patient reporting sudden sharp and severe upper back pain could potentially have an aortic dissection, which is a life-threatening condition that requires immediate evaluation and treatment. Therefore, this patient should be assessed first14.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Intermittent claudication and pallor are not typically symptoms of a myocardial infarction. Intermittent claudication, or pain in the legs with exercise, is more commonly associated with peripheral artery disease. Pallor, or paleness, can occur with various conditions but is not a specific sign of myocardial infarction3.
Choice B rationale
Jugular vein distention and dependent edema are not typically symptoms of a myocardial infarction. These signs are more commonly associated with heart failure3.
Choice C rationale
Mid-epigastric pain and heartburn can sometimes be symptoms of a myocardial infarction, particularly in women. However, these symptoms can also occur with many other conditions, including gastrointestinal disorders3.
Choice D rationale
Sweating and cool, clammy skin are common symptoms of a myocardial infarction. These symptoms occur due to the body’s stress response to the decreased blood flow to the heart muscle3.
Correct Answer is C
Explanation
Choice A rationale
This sequence is incorrect because it suggests that blood goes from the lungs to the pulmonary artery, which is not accurate. The pulmonary artery carries deoxygenated blood from the heart to the lungs.
Choice B rationale
This sequence is incorrect because it suggests that blood goes from the pulmonary vein to the lungs, which is not accurate. The pulmonary vein carries oxygenated blood from the lungs to the heart.
Choice C rationale
This sequence correctly describes the direction of blood flow through the heart and lungs. Deoxygenated blood enters the right atrium, goes to the right ventricle, then is sent to the lungs via the pulmonary artery. After picking up oxygen in the lungs, the blood returns to the heart via the pulmonary vein, entering the left atrium, then the left ventricle, from where it is pumped out to the rest of the body.
Choice D rationale
This sequence is incorrect because it suggests that blood goes from the pulmonary vein to the pulmonary artery, which is not accurate. The pulmonary vein carries oxygenated blood from the lungs to the heart, and the pulmonary artery carries deoxygenated blood from the heart to the lungs.
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