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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale
Venous thrombosis is a condition in which a blood clot forms in a vein, typically in the leg. While this condition can cause discomfort and changes in the appearance of the leg, it would not typically cause the leg to become cold and pale or result in the loss of a pulse.
Choice B rationale
Paresthesia refers to abnormal sensations in the body, such as tingling, numbness, or burning. While this condition could potentially cause discomfort, it would not typically cause the leg to become cold and pale or result in the loss of a pulse.
Choice C rationale
Vascular spasm is a sudden, brief tightening of the muscles inside the walls of a blood vessel. While this could potentially cause discomfort and changes in the appearance of the leg, it would not typically cause the leg to become cold and pale or result in the loss of a pulse.
Choice D rationale
Arterial occlusion is the correct answer. This condition involves a blockage in an artery, which can significantly reduce blood flow to the affected area. This could cause the leg to become cold and pale and result in the loss of a pulse.

A. Palpable liver edge 2 cm below the ribs on the right side. B. Serum potassium level of 3.0 mEq/L after 1 week of therapy. C. Weight increase from 120 pounds to 122 pounds over 3 days. D. Presence of 1+ to 2+ edema in the feet and ankles.

Correct Answer is B

Explanation

Choice A rationale
While palpating the liver edge can provide information about liver health and potential fluid accumulation, it is not typically a priority assessment for a patient taking Digoxin (Lanoxin), Furosemide (Lasix), and Captopril.
Choice B rationale
A serum potassium level of 3.0 mEq/L is low (hypokalemia). This is a critical finding because both Digoxin and Furosemide can cause hypokalemia. Hypokalemia increases the risk of digoxin toxicity, which can lead to serious cardiac arrhythmias.
Choice C rationale
While weight gain may indicate worsening heart failure, a gain of 2 pounds over 3 days is not typically considered significant. However, any sudden or unexplained weight gain should be reported to the healthcare provider.
Choice D rationale
Presence of 1+ to 2+ edema in the feet and ankles could indicate worsening heart failure, but it is not as immediately concerning as hypokalemia in a patient taking Digoxin and Furosemide.

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After receiving the shift change report about four patients in the cardiac care unit, which patient should the nurse prioritize for assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An obese post-surgical patient reports sudden discomfort in her leg. Upon assessment, the nurse finds the leg to be cold and pale, with no pedal or popliteal pulse. What should the nurse suspect?

Correct Answer is D

Explanation

A patient with heart failure has recently started taking Digoxin (Lanoxin), Furosemide (Lasix), and Captopril. Which finding by the home health nurse is a priority to communicate to the healthcare provider?

Correct Answer is B

Explanation

Which medication, when noted in a patient’s history, will diminish the effects of Warfarin (Coumadin)?

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