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. A normal QRS duration is 0.06–0.10 seconds. A duration of 0.20 seconds indicates a ventricular conduction delay or bundle branch block, which is not normal sinus rhythm.
B. A normal PR interval is 0.12–0.20 seconds. A measurement of 0.22 seconds suggests a first-degree heart block, which is an abnormal finding.
C. Normally, T waves are upright in most leads. Inverted T waves can indicate ischemia, infarction, or electrolyte disturbances, which are not consistent with normal sinus rhythm.
D. In normal sinus rhythm, the P wave precedes each QRS complex, reflecting proper atrial depolarization followed by ventricular depolarization. This relationship confirms that the electrical impulse is originating from the sinoatrial (SA) node, which defines normal sinus rhythm.
Correct Answer is D
Explanation
Rationale:
A. A barrel chest is typically associated with chronic obstructive pulmonary disease (COPD) due to chronic hyperinflation of the lungs, not mitral valve stenosis.
B. Clubbing occurs in chronic hypoxia conditions such as congenital heart defects or long-term lung disease. It is not a primary feature of mitral stenosis.
C. Mitral stenosis does not typically cause bradycardia. Some clients may develop atrial fibrillation, which usually causes irregularly rapid heart rates, not slowed heart rate.
D. Mitral valve stenosis narrows the mitral valve, causing turbulent blood flow from the left atrium to the left ventricle during diastole. This produces a diastolic murmur, often heard best at the apex with the client in the left lateral position.
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