The nurse has received a change-of-shift report on the following clients. Which client should the nurse see first?

A patient with second-degree atrioventricular (AV) block, type 1. rate 60, who is dizzy when ambulating

A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago

A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due

A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due.

Answer and Explanation

The Correct Answer is D

A. A patient with second-degree atrioventricular (AV) block, type 1, rate 60, who is dizzy when ambulating. While dizziness may be a concern, second-degree AV block type 1 (Wenckebach) typically resolves without immediate intervention.

B. A patient who is in a sinus rhythm, rate 98 and regular, recovering from an elective cardioversion 2 hours ago. This patient is stable, and recovery from cardioversion typically involves monitoring, but the patient does not require immediate intervention.

C. A patient with atrial fibrillation, rate 88 and irregular, who has a dose of warfarin (Coumadin) due. The patient is stable, and the dose of warfarin can be administered after assessing the patient’s overall condition, making it a lower priority.

D. A patient whose implantable cardioverter-defibrillator (ICD) fired twice today and has a dose of amiodarone (Cordarone) due: The patient whose ICD fired twice is at high risk for life-threatening arrhythmias, and this situation requires immediate evaluation and intervention. The nurse should assess the patient first, and the dose of amiodarone may be administered to manage any underlying arrhythmias.

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Correct Answer is D

Explanation

A. Maintain hyperventilation to a PaCO2 of 15 to 20 mm Hg. Hyperventilation can reduce ICP by causing vasoconstriction of cerebral blood vessels; however, a PaCO2 as low as 15–20 mmHg may lead to excessive vasoconstriction, reducing cerebral blood flow and causing cerebral ischemia. A PaCO2 target closer to 30–35 mmHg is typically recommended, and even this is used cautiously.

B. Routinely suction to prevent accumulation of respiratory secretions. Suctioning can increase ICP due to stimulation of the cough reflex. It should be performed only as needed and in a way that minimizes stimulation, such as preoxygenation and limiting suction duration.

C. Encourage visitation to prevent feelings of isolation. While social support is important, minimizing environmental stimuli (including limiting visitation) is crucial for clients with increased ICP to prevent overstimulation and further increases in ICP.

D. Avoid positioning the client with neck and hip flexion. Maintaining proper alignment of the head and neck is essential to promote venous drainage and reduce intracranial pressure (ICP). Flexion of the neck or hips can impede venous outflow, exacerbate ICP, and compromise cerebral perfusion.

A. Urine glucose, high B. Urine specific gravity, 1.001 C. Urine output, 50 ml/hr D. Urine protein, high

Correct Answer is B

Explanation

A. Urine glucose, high: High urine glucose would suggest hyperglycemia, typically seen in diabetes mellitus, not diabetes insipidus.

B. Urine specific gravity, 1.001: Diabetes insipidus results in excessive urine output with a low specific gravity (dilute urine), reflecting the inability to concentrate urine.

C. Urine output, 50 ml/hr: This is a relatively low urine output, which does not indicate diabetes insipidus. Diabetes insipidus is characterized by very high urine output, often greater than 3 liters per day.

D. Urine protein, high: High urine protein could suggest kidney disease or glomerular injury, not diabetes insipidus.

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The nurse has received a change-of-shift report on the following clients. Which client should the nurse see first?

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