After reviewing a patient's history, vital signs, physical assessment, and laboratory data, which information is most important for the nurse to communicate to the health care provider?.
Elevated troponin.
Q Waves on ECG.
Bilateral crackles.
Hyperglycemia.
The Correct Answer is A
Choice A rationale:
Elevated troponin is a sign of heart damage, which could be caused by a heart attack or other stresses on the heart. This is a critical finding that needs immediate attention.
Choice B rationale:
Q waves on an ECG can indicate a previous heart attack or myocardial infarction. However, they can also be a normal variant, meaning they are a harmless variation in the electrical activity of the heart.
Choice C rationale:
Bilateral crackles in the lungs can indicate mucus or fluid in the base of the lungs, often associated with conditions like pneumonia, heart failure, or bronchitis.
Choice D rationale:
Hyperglycemia, or high blood glucose, can be a sign of diabetes. If untreated, it can lead to serious complications like ketoacidosis.
So, the correct answer is Choice A, after analyzing all choices.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","F"]
Explanation
Choice A rationale:
The client’s temperature decreased from 37.6°C to 36.8°C1. This is within the normal body temperature range of 36.5°C to 37.2°C2, so it does not require further action.
Choice B rationale:
The client’s oxygen saturation decreased from 95% to 88%1. Normal pulse oximetry values are typically above 95%2. This decrease could indicate that the client is not getting enough oxygen, which requires further action.
Choice C rationale:
The client’s blood pressure increased from 108/50 mm Hg to 138/80 mm Hg. Normal blood pressure for adults is below 120/80 mm Hg. This increase could indicate worsening heart failure, which requires further action.
Choice D rationale:
The client’s weight increased from 80 kg to 82.1 kg. Rapid weight gain may be a sign of fluid retention, a common symptom of heart failure. This requires further action.
Choice E rationale:
The client’s urine output decreased from 480 mL/8 hr to 320 mL/8 hr.However it is still above 30ml/hr signifying normal renal function
Choice F rationale:
On Day 4, the client’s breath sounds were scattered, and crackles were heard bilaterally. This could indicate fluid accumulation in the lungs, a common symptom of heart failure. This requires further action.
So, the correct answer is Choices B, C, D, and F, after analyzing all choices.
Correct Answer is B
Explanation
Choice A rationale:
While bilateral crackles at the lung bases indicate fluid accumulation, a common symptom of dilated cardiomyopathy, it’s not as immediately life-threatening as some other conditions.
Choice B rationale:
Acute aortic regurgitation can lead to a rapid and severe drop in blood pressure, which is a medical emergency. Therefore, this patient should be assessed first.
Choice C rationale:
While a murmur and splinter hemorrhages are symptoms of infective endocarditis, they are not as immediately life-threatening as acute aortic regurgitation.
Choice D rationale:
Sharp chest pain with a deep breath could be a symptom of rheumatic fever, but it’s not as immediately life-threatening as acute aortic regurgitation.
So, the correct answer is Choice B, after analyzing all choices.
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