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 C
Explanation
A. Sinus bradycardia is characterized by a heart rate less than 60 beats/min, but in this case the rate is exactly 60, which is normal lower limit.
B. First degree heart block involves a prolonged PR interval (>0.20 seconds); here, the PR interval is normal (0.16 seconds).
C. Normal sinus rhythm has regular P waves and QRS complexes, a normal PR interval (0.12–0.20 seconds), and a heart rate between 60–100 beats/min.
D. Sick sinus syndrome is characterized by irregular rhythms and abnormal sinus node function, which is not indicated here.
Correct Answer is A
Explanation
A. Hepatomegaly (enlarged liver) is a classic sign of right ventricular failure due to systemic venous congestion.
B. A dry, hacking cough is more commonly associated with left-sided heart failure and pulmonary congestion.
C. Crackles in the lungs result from fluid backing up into the lungs, a hallmark of left-sided heart failure, not right-sided.
D. Dizziness may occur in left-sided failure due to decreased cardiac output and poor cerebral perfusion, but it is not a key feature of right-sided failure.
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