The night nurse in the cardiac ICU has just received a report on several patients. Which of the following clients should the nurse prioritize for rounds?

A patient with a new-onset of confusion and restlessness.

A patient who reports dizziness after receiving captopril (Capoten).

A patient who requires oxygen via nasal cannula with saturations of 97%.

A patient who has received digoxin and has a blood pressure (BP) of 100/56.

Answer and Explanation

The Correct Answer is A

Choice A reason: A patient with a new-onset of confusion and restlessness is a priority because these symptoms could indicate a serious condition such as hypoxia, electrolyte imbalance, or a neurological event like a stroke. These changes in mental status need to be evaluated immediately to prevent further complications.

Choice B reason: Dizziness after receiving captopril (Capoten) can be a side effect of the medication due to its blood pressure-lowering effects. While it should be monitored, it is not as urgent as the new-onset confusion and restlessness seen in another patient.

Choice C reason: A patient requiring oxygen via nasal cannula with saturations of 97% is stable as the oxygen saturation is within normal limits. This patient does not need to be prioritized over others with more acute symptoms.

Choice D reason: A patient who has received digoxin and has a blood pressure of 100/56 should be monitored, especially for signs of digoxin toxicity. However, this situation is not as critical as the new-onset confusion and restlessness in another patient.

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Correct Answer is C

Explanation

Choice A reason: Consuming a high purine diet is not related to myasthenic crisis. High purine diets are more commonly associated with conditions like gout, where uric acid levels become elevated.

Choice B reason: Taking too much of their medication can lead to a cholinergic crisis, not a myasthenic crisis. A cholinergic crisis occurs due to excessive accumulation of acetylcholine, often from overmedication with anticholinesterase drugs.

Choice C reason: Taking too little of the prescribed medication is the primary precipitating factor for a myasthenic crisis. Inadequate levels of medication lead to insufficient acetylcholine at neuromuscular junctions, causing severe muscle weakness and potentially life-threatening respiratory failure. This situation requires immediate medical intervention to stabilize the patient.

Choice D reason: Taking medication on an empty stomach may affect absorption rates, but it is not a direct precipitating factor for a myasthenic crisis. The crisis is more closely linked to under-medication or missed doses of anticholinesterase drugs.

A. The bright light in this room is really bothering me B. It's hard to see with a patch on one eye, I'm afraid of falling C. My eye really itches but I'm trying not to rub it D. I need something for the pain in my eye, I can't stand it

Correct Answer is D

Explanation

Choice A reason: Bright light sensitivity is a common side effect following cataract surgery and can be managed with appropriate measures such as wearing sunglasses. It does not necessarily indicate a complication requiring immediate reporting.

Choice B reason: Difficulty seeing with a patch on one eye and fear of falling are valid concerns, but they do not necessarily indicate an immediate complication that requires urgent reporting to the healthcare provider.

Choice C reason: Eye itching is common after cataract surgery, and the client should be advised not to rub the eye to prevent infection or damage. This comment does not indicate a severe complication that needs immediate reporting.

Choice D reason: Severe eye pain that the client cannot stand is a potential sign of a serious complication, such as increased intraocular pressure, infection, or other postoperative issues. This requires immediate attention from the healthcare provider to prevent further complications and ensure the client's safety.

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The night nurse in the cardiac ICU has just received a report on several patients. Which of the following clients should the nurse prioritize for rounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the hospital with a myasthenic crisis. The nurse should anticipate which potential precipitating factors for this event?

Correct Answer is C

Explanation

A nurse is caring for a client following cataract surgery. Which comment from the client should the nurse report to the client's health care provider IMMEDIATELY?

Correct Answer is D

Explanation

The charge nurse observes a nurse performing interventions for a client who has just arrived in the post-anesthesia care unit following right cataract removal and intraocular lens implantation. Which intervention would require the charge nurse to intervene?

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which manifestations of peritonitis?

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The nurse is assessing a client's eyes and notes that when the client looks at a near object, the pupil constricts, but when the client looks at an object in the distance, the pupil dilates. The nurse should identify this finding as which condition?

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A client seen in the clinic with shortness of breath and fatigue is being evaluated for a possible diagnosis of heart failure. Which laboratory result will be the most useful to monitor?

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?