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 ["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.
Correct Answer is C
Explanation
Rationale:
A. While assessing vital signs is important, blood pressure alone cannot confirm or rule out a myocardial infarction (MI); it only provides information about hemodynamic status.
B. Heart sounds may reveal murmurs or extra sounds but cannot definitively diagnose an MI.
C. A 12-lead ECG is the primary diagnostic tool for identifying an acute MI, as it can detect ST-segment changes, T-wave inversions, or Q waves indicative of myocardial injury or ischemia.
D. Pain radiation is a clinical symptom that supports suspicion of MI, but symptoms alone cannot confirm the diagnosis; objective evidence from ECG and cardiac biomarkers is required.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.