After receiving report on the following clients, which client should the nurse assess first?

Client with infective endocarditis who has a murmur and splinter hemorrhages

Client with rheumatic fever who has sharp chest pain with a deep breath

Client with dilated cardiomyopathy who has bilateral crackles at the lung bases

Client with acute aortic regurgitation whose blood pressure is 86/54 mm Hg

Answer and Explanation

The Correct Answer is D

A. A murmur and splinter hemorrhages are expected findings in infective endocarditis and do not indicate an immediate life-threatening condition.
B. Sharp chest pain with inspiration in rheumatic fever may indicate pericarditis, which needs monitoring but is not immediately unstable.
C. Bilateral crackles suggest fluid overload in dilated cardiomyopathy, requiring attention, but not as urgent as hypotension in acute valve failure.
D. Acute aortic regurgitation with hypotension (BP 86/54 mm Hg) indicates a possible hemodynamic collapse and cardiogenic shock, making this client the highest priority for immediate assessment and intervention.

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Correct Answer is C

Explanation

A. In the refractory stage, cardiac output is decreased and tissue perfusion is severely impaired, not improved.
B. Fluid balance is not restored during the refractory stage; instead, hypovolemia worsens.
C. The refractory stage is characterized by irreversible damage with worsening organ dysfunction and failure despite interventions.
D. Heart rate usually increases initially, and blood pressure typically decreases; decreased heart rate and improved blood pressure are not features of this stage.

A. Increased blood pressure B. Increase hematocrit C. Increased respiratory rate D. Increased heart rate E. Increased temperature

Correct Answer is ["A","C","D"]

Explanation

A. Increased blood pressure occurs due to excess fluid volume increasing vascular pressure.
B. Hematocrit typically decreases in fluid overload due to dilution, not increases.
C. Increased respiratory rate is common due to pulmonary congestion or edema.
D. Increased heart rate occurs as the heart works harder to manage the excess fluid volume.
E. Increased temperature is not a typical finding in fluid overload.

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After receiving report on the following clients, which client should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the refractory stage of shock in hypovolemia, which of the following responses accurately describes the physiological changes that occur?

Correct Answer is C

Explanation

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

A client with aortic regurgitation is being transferred from the critical care unit to the step-down unit. The nurse receiving the patient in the step-down unit is aware that aortic regurgitation causes:

The nurse who is caring for a client in ICU on a ventilator assesses a need for suctioning and is aware that the most common cardiac arrhythmia occurring during endotracheal suctioning is:

Nurses in intensive care units commonly care for clients in varying stages of various types of shock. Which of the following is the most common cause of death in intensive care units in the United States?

A client who has been transported to the emergency room after a motor vehicle accident is experiencing asystole. Management of asystole focuses on:

A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions?

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Which of the following statements best describes the pathophysiologic rationale for shock?

An client being assessed in the emergency room is anxious about their health status. The ECG rhythm strip shows a heart rate of 120 beats/min. Characteristics of a sinus tachycardia rhythm are