After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient should the nurse assess first?
A patient who has crackles bilaterally in the lung bases and is receiving oxygen with oxygen saturation of 95%
A patient who is receiving IV nitroglycerin and has a blood pressure of 108/62
A patient who is cool and clammy, with new-onset confusion and restlessness
A patient who reported dry cough after receiving the first dose of captopril
The Correct Answer is C
Rationale:
A. This patient shows signs of mild pulmonary congestion, but oxygen saturation is within an acceptable range and the patient is currently stable.
B. While this patient is on a vasodilator and has borderline low blood pressure, they are hemodynamically stable at this moment and not showing signs of acute deterioration.
C. This patient exhibits signs of poor perfusion and possible cardiogenic shock, which is life-threatening. These symptoms indicate an urgent priority for assessment and intervention.
D. This is a common side effect of ACE inhibitors and is non-emergent; the patient is stable and does not require immediate assessment
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. While documentation is important, a weight gain of ≥2 lb (≈1 kg) in 1–3 days and generalized edema indicates fluid retention and possible worsening heart failure, which requires immediate provider notification, not just documentation.
B. Although adherence to diuretics is important, simply confirming this does not address the acute risk of fluid overload and possible decompensation. Immediate action is required.
C. Education is important for prevention, but in this case, the patient is already showing signs of worsening heart failure, so reinforcing education alone is insufficient.
D. Rapid weight gain and generalized edema over a short period are red flags for fluid overload. The nurse should contact the provider immediately to report findings and receive guidance for interventions such as adjusting medications, evaluating for hospitalization, or further monitoring.
Correct Answer is B
Explanation
Rationale:
A. Cardiac enzyme tests indicate myocardial injury but do not pinpoint the exact location of the infarct; imaging or ECG is required for localization.
B. Cardiac enzymes, such as troponin and creatine kinase-MB (CK-MB), are released into the bloodstream when myocardial cells are damaged. Their levels correlate with the extent of cardiac tissue injury, helping providers assess severity and guide treatment.
C. Pulmonary congestion is assessed via physical examination, chest X-ray, or echocardiography, not cardiac enzyme levels.
D. Structural assessment requires echocardiography or other imaging, not blood enzyme studies.
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