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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Sodium bicarbonate is used to treat metabolic acidosis and is not indicated for symptomatic bradycardia.
Choice B reason: Atropine is the first-line medication for symptomatic bradycardia. It works by blocking the vagus nerve's effects on the heart, increasing heart rate. It is commonly used in emergency settings to manage bradycardia until a more definitive treatment, such as pacemaker insertion, can be provided.
Choice C reason: Magnesium is typically used to treat torsades de pointes, a specific type of ventricular tachycardia, and is not indicated for symptomatic bradycardia.
Choice D reason: Amiodarone is an antiarrhythmic medication used to manage various types of arrhythmias, including ventricular tachycardia and fibrillation, but it is not indicated for symptomatic bradycardia.
Correct Answer is A
Explanation
Choice A reason: This response acknowledges the client's feelings and validates their experience. It opens the door for the client to express their emotions and share their thoughts. This empathetic approach helps build trust and provides emotional support.
Choice B reason: Telling the client that it takes time to get over the loss of a loved one is a generalized statement that may not provide the support the client needs. It can come across as dismissive and may not encourage further conversation.
Choice C reason: Suggesting that the client try something to take their mind off their troubles can seem dismissive of their grief. It does not address the client's emotional needs or encourage them to talk about their feelings.
Choice D reason: While this response shows some understanding, it does not fully acknowledge the uniqueness of the client's situation. It is important to validate the client's feelings and encourage them to express their emotions.
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