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

Answer and Explanation

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

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

Explanation

Rationale:

A. LDL cholesterol levels are used to assess a patient’s long-term risk for atherosclerosis and cardiovascular disease, but they do not rise acutely during myocardial infarction and therefore are not useful for diagnosing an MI in the emergency setting.

B. Myoglobin is a small heme protein released rapidly from damaged cardiac and skeletal muscle. It can appear in the blood within 1–4 hours after myocardial injury, making it useful for early detection of myocardial infarction. However, it is not specific to cardiac muscle, so elevations could also occur with skeletal muscle injury. Myoglobin is often used in conjunction with other cardiac biomarkers.

C. Blood urea nitrogen reflects renal function and may increase in kidney disease or dehydration, but it does not indicate myocardial injury and is not part of the standard diagnostic workup for acute MI.

D. Troponin I and T are structural proteins of cardiac muscle, and their levels rise within 3–6 hours after myocardial injury and remain elevated for up to 10–14 days. They are highly sensitive and specific for cardiac injury, making troponin the gold standard for confirming myocardial infarction.

E. Creatinine measures kidney function and may be monitored in patients receiving contrast dye or nephrotoxic drugs, but it does not aid in diagnosing an acute MI.

A. "I will need to increase my fluids to 3 liters per day? B. I should avoid driving due to my implanted defibrillator C. "I should refrain from sexual activity while taking NSAIDS D. "I will contact my health care provider if i develop chest pain.

Correct Answer is D

Explanation

Rationale:
A. While adequate hydration is generally beneficial, pericarditis management does not typically require aggressive fluid intake, and overhydration could exacerbate complications, especially if there is concurrent heart failure.

B. This statement is not relevant to pericarditis, as having pericarditis does not necessitate avoidance of driving unless there are specific complications or comorbidities.

C. NSAIDs are used to reduce inflammation and pain in pericarditis; sexual activity is not contraindicated while on these medications unless the client is experiencing symptoms that limit activity.

D. This indicates understanding because chest pain can signify worsening pericarditis or complications such as cardiac tamponade or myocardial involvement, and prompt evaluation is necessary.

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After receiving change-of-shift report on four patients admitted to a heart failure unit, which patient should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply)

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

Explanation

A nurse is teaching a client about the management of pericarditis. Which off the following client statements indicates to the nurse an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?

A nurse cares for a client who manifests Ventricular Tachycardia on a cardiac monitor. Which action should the nurse take first?

A nurse is teaching a group of clients about risk factors for developing atrial flutter. Which of the following clients should the nurse understand is at highest risk for developing atrial flutter?

A nurse is reviewing the laboratory values of a client who had a myocardial infarction 3 hr ago. The nurse should expect which of the following laboratory values to be elevated?

A nurse is reviewing laboratory results for a client who has pericarditis. Which of the following blood test results should the nurse anticipate? (Select All that Apply.)

Which of the following is the initial step in the management of a patient with asystole?

A patient's heart monitor shows HR 78 with progressive lengthening of the PR interval over time. What is the most appropriate action for the nurse to take next?

A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification?