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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Oliguria (low urine output) is an expected finding in hypovolemic shock due to decreased renal perfusion as blood is shunted to vital organs.
B. Hypertension is not expected; hypotension is more typical as circulating blood volume decreases.
C. Bradypnea is not common; tachypnea is expected as the body tries to compensate for decreased oxygen delivery.
D. Flushing of the skin is associated with early septic shock; in hypovolemic shock, the skin is typically cool, pale, and clammy due to peripheral vasoconstriction.
Correct Answer is A
Explanation
A. The presence of prosthetic heart valves is a significant risk factor for infective endocarditis due to the increased likelihood of bacterial colonization.
B. Sedentary lifestyle is not a direct risk factor for infective endocarditis, though it may contribute to other cardiovascular issues.
C. Radiation exposure – While it may affect cardiac tissue, it is not considered a risk factor for infective endocarditis.
D. Cardiac catheterization – While it is an invasive procedure, it is not a major or common risk factor for infective endocarditis compared to prosthetic valves or structural heart defects.
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