After receiving change-of-shift report on a heart failure unit, which client should the nurse assess first?
Client who is taking digoxin and has a potassium level of 3.1 mEq/L
Client who is taking captopril and has a frequent nonproductive cough
Client who is taking carvedilol (Coreg) and has a heart rate of 58
Client who is taking isosorbide dinitrate/hydralazine (BiDil) and has a headache
The Correct Answer is D
The client taking isosorbide dinitrate/hydralazine (BiDil) and experiencing a headache should be assessed first. Isosorbide dinitrate/hydralazine is a medication combination used to treat heart failure, particularly in African American patients. However, one of the side effects of hydralazine is headaches.
Headache in a client taking this medication may indicate increased blood pressure as a compensatory response to vasodilation. If not addressed promptly, it may lead to worsening heart failure or other complications. Therefore, it is essential to assess the client's blood pressure, signs of worsening heart failure, and evaluate the severity and duration of the headache.
The other options may also require attention:
A) A client taking digoxin with a potassium level of 3.1 mEq/L needs assessment, as hypokalemia can increase the risk of digoxin toxicity. However, the headache in the BiDil client takes priority due to the potential complications related to increased blood pressure.
B) A client taking captopril and experiencing a frequent nonproductive cough may indicate a side effect of the medication. While it should be assessed, it is not as immediately concerning as the headache in the BiDil client.
C) A client taking carvedilol (Coreg) with a heart rate of 58 is within an acceptable range, especially if the client is tolerating it well without symptoms. It may not require immediate assessment unless there are other concerning symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Cloudy peritoneal effluent may indicate infection or peritonitis, which is a severe complication of peritoneal dialysis. Peritonitis can be life-threatening and requires immediate medical attention. The nurse should report this finding promptly to the health care provider for further evaluation and intervention.
Correct Answer is B
Explanation
Jugular venous distention (JVD) is a clinical sign that indicates increased fluid volume or fluid overload in the cardiovascular system. When the head of the client's bed is elevated at 45 degrees, the jugular veins should normally be flat or slightly distended. However, if the jugular veins appear engorged and bulging, it suggests that there is an increased amount of blood returning to the right side of the heart and is unable to be efficiently pumped forward, leading to jugular venous distention.
JVD is commonly seen in conditions such as heart failure, where the heart's ability to pump blood efficiently is compromised, leading to fluid accumulation in the veins and eventually causing jugular venous distention.
Option A, jugular vein atherosclerosis, is not a common cause of JVD. Atherosclerosis refers to the build-up of plaque within arteries, not veins.
Option C, decreased fluid volume, would lead to dehydration and decreased venous filling, which would not cause jugular venous distention. It would lead to flat or sunken jugular veins.
Option D, incompetent jugular vein valves, would not cause jugular venous distention with the head of the bed elevated. Incompetent valves may lead to venous reflux or backward flow of blood, but it would not lead to the distention of the jugular veins in this position.
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