The nurse has received SBAR report for their four assigned patients on a cardiac unit. Which patient will the nurse prioritize to assess first?

The patient newly diagnosed with heart failure whose pulse oximetry is 94% on 2L oxygen.

A patient scheduled for echocardiogram who has altered level of consciousness and restlessness.

The patient who has dyspnea on exertion but wants to be discharged against medical advice.

The patient whose ejection fraction (EF) is 50% and has 2+ bilateral lower extremity edema.

Answer and Explanation

The Correct Answer is B

Choice A reason: The patient with heart failure whose pulse oximetry is 94% on 2L oxygen is stable at the moment. While they require monitoring, they do not take immediate priority over the patient with altered consciousness.

Choice B reason: Altered level of consciousness and restlessness are critical symptoms that require immediate assessment. These could indicate a life-threatening condition such as hypoxia, electrolyte imbalance, or stroke, necessitating prompt evaluation and intervention.

Choice C reason: The patient with dyspnea on exertion who wants to be discharged against medical advice is important, but altered consciousness takes precedence due to its potential severity.

Choice D reason: The patient with an ejection fraction of 50% and 2+ bilateral lower extremity edema is stable and does not require immediate intervention compared to the patient with altered consciousness.

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Free Nursing Study Resources

Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Ulcers in the descending colon are indicative of Crohn's disease, which affects any part of the gastrointestinal tract.

Choice B reason: Absence of narrowing of the colon and mucosal edema is more indicative of ulcerative colitis rather than Crohn's disease.

Choice C reason: Fistulas and perianal involvement are common complications of Crohn's disease due to the transmural inflammation.

Choice D reason: Mild bleeding and an abdominal mass can be associated with both Crohn's disease and other gastrointestinal disorders, making it less specific.

Choice E reason: Regional, discontinuous skip lesions are a hallmark of Crohn's disease, seen on barium studies, indicating areas of inflammation separated by normal tissue.

A. Perform weekly occult blood testing with gastric analysis test. B. Discuss nutritional management with inclusion of high-protein, high-vitamin diet. C. Leave ostomy site open to air for an hour each day when changing the appliance. D. Instruct the patient and family how to give medications through their G-tube.

Correct Answer is B

Explanation

Choice A reason: Performing weekly occult blood testing with gastric analysis is not typically required for managing IBD at home. This intervention is more invasive and usually performed under specific medical instructions rather than as a routine home care intervention.

Choice B reason: Discussing nutritional management with the inclusion of a high-protein, high-vitamin diet is crucial for patients with IBD. These patients often experience malnutrition due to poor absorption and increased nutritional needs during flare-ups. A high-protein, high-vitamin diet can help promote healing, maintain muscle mass, and prevent deficiencies.

Choice C reason: Leaving the ostomy site open to air for an hour each day when changing the appliance is not recommended. Ostomy sites need to be kept clean and protected to prevent infection and skin irritation.

Choice D reason: Instructing the patient and family on how to give medications through their G-tube is not relevant if the patient has an ileostomy. The focus should be on ostomy care and management

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The nurse has received SBAR report for their four assigned patients on a cardiac unit. Which patient will the nurse prioritize to assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a patient whose health history is suggestive of inflammatory bowel disease. Which clinical manifestations and diagnostic findings confirm the diagnosis of Crohn's disease? (Select All That Apply)

Correct Answer is ["A","C","E"]

Explanation

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Correct Answer is B

Explanation

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