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
Explanation
Rationale:
A. Typically causes pulmonary symptoms, such as dyspnea, orthopnea, and pulmonary edema, rather than peripheral edema and hepatomegaly.
B. Right-sided HF leads to systemic venous congestion, causing peripheral edema, jugular venous distention, hepatomegaly, and abdominal discomfort. Weight gain from fluid retention is also common.
C. Can cause ascites and hepatomegaly, but usually accompanied by stigmata of chronic liver disease (jaundice, spider angiomas) and not jugular venous distention due to cardiac causes.
D. May cause generalized edema and weight gain, but jugular venous distention and hepatomegaly are less specific, and lab findings (BUN, creatinine) would help distinguish.
Correct Answer is A
Explanation
Rationale:
A. In acute heart failure, especially following an MI, clients are at risk for fluid volume overload. Administering a relatively large volume of isotonic fluid could exacerbate pulmonary edema and worsen heart failure. This prescription requires clarification with the provider before administration.
B. Furosemide is a loop diuretic commonly prescribed to reduce fluid overload in heart failure. This prescription is appropriate for managing pulmonary congestion and edema.
C. Monitoring electrolytes, particularly potassium, is essential in heart failure patients receiving diuretics. This helps prevent dysrhythmias and is appropriate.
D. Morphine may be used in acute heart failure to relieve anxiety and dyspnea; this prescription is appropriate as ordered.
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