After receiving the shift change report about four patients in the cardiac care unit, which patient should the nurse prioritize for assessment?
A 59-year-old patient with unstable angina who has just returned from a percutaneous coronary intervention (PCI).
A 56-year-old patient with variant angina due to receive nifedipine (Procardia).
A 65-year-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about discharge planned for today.
A 39-year-old patient with pericarditis complaining of sharp, stabbing chest pain.
The Correct Answer is A
Choice A rationale
A 59-year-old patient with unstable angina who has just returned from a percutaneous coronary intervention (PCI) should be prioritized for assessment. PCI is a procedure to open blocked or narrowed coronary arteries and can lead to complications such as re-occlusion of the artery or bleeding from the catheter insertion site. Furthermore, unstable angina is a condition that can progress to myocardial infarction if not managed effectively.
Choice B rationale
A 56-year-old patient with variant angina due to receive nifedipine (Procardia) requires monitoring, but is not the highest priority. Variant angina is a form of angina that occurs at rest, often with severe pain, but it is usually well-controlled with medications like nifedipine.
Choice C rationale
A 65-year-old patient who had a myocardial infarction (MI) 4 days ago and is anxious about discharge planned for today is a lower priority for assessment. While it’s important to address the patient’s anxiety and provide education about post-discharge care, this patient is not in immediate danger.
Choice D rationale
A 39-year-old patient with pericarditis complaining of sharp, stabbing chest pain requires assessment, but is not the highest priority. Pericarditis is inflammation of the pericardium, the sac-like covering of the heart, and while it can cause severe pain, it is not typically life- threatening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
High-output heart failure is not typically associated with chronic pulmonary disease and elevated pulmonary vascular resistance. High-output heart failure occurs when the heart is unable to meet the body’s increased demand for blood flow, which is not the case in this scenario.
Choice B rationale
Low-output heart failure is also not typically associated with chronic pulmonary disease and elevated pulmonary vascular resistance. Low-output heart failure occurs when the heart is unable to pump enough blood to meet the body’s needs, which is not the case in this scenario.
Choice C rationale
Left heart failure is not typically associated with chronic pulmonary disease and elevated pulmonary vascular resistance. Left heart failure occurs when the left side of the heart is unable to pump enough blood to the body, which is not the case in this scenario.
Choice D rationale
Right heart failure is the correct answer. In the context of a 65-year-old male patient diagnosed with chronic pulmonary disease and elevated pulmonary vascular resistance, the nurse should assess for right heart failure. This is because the right side of the heart pumps blood to the lungs, and if the pulmonary vascular resistance is elevated, it can put strain on the right side of the heart, leading to right heart failure.
Correct Answer is A
Explanation
Choice A rationale
Bleeding from the gums is a sign of excessive bleeding, which can be a side effect of thrombolytic therapy. Thrombolytic agents work by dissolving blood clots, but they can also interfere with the body’s normal clotting mechanism, leading to bleeding. If a patient experiences unusual or excessive bleeding, it may be necessary to stop the infusion of the thrombolytic agent.
Choice B rationale
An increase in blood pressure is not typically a reason to stop the infusion of a thrombolytic agent in a patient with an acute myocardial infarction. While blood pressure should be monitored closely during thrombolytic therapy, an increase in blood pressure is not a common side effect.
Choice C rationale
A nonsustained episode of ventricular tachycardia is not typically a reason to stop the infusion of a thrombolytic agent in a patient with an acute myocardial infarction. While arrhythmias can occur during a myocardial infarction, they are not a common side effect of thrombolytic therapy.
Choice D rationale
A decreased level of consciousness can be a sign of many serious conditions, including bleeding in the brain. However, it is not typically a reason to stop the infusion of a thrombolytic agent unless it is accompanied by other signs of excessive bleeding.
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